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On  the  Origin  and  Progress  of 
Renal  Surgery. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


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ON   THE 


ORIGIN  AND   PROGRESS 


RENAL   SURGERY 


WITH    SPECIAL    REFERENCE   TO    STONE    IN    THE    KIDNEY 
AND  URETER  ;  AND  TO  THE   SURGICAL  TREAT- 
MENT   OF    CALCULOUS    ANURIA 


Being  tbe  Ibunterian  Xectures  for  1898 


TOGETHER    WITH 


A  CRITICAL  EXAMINATION  OF  SUBPARIETAL  INJURIES 
OF  THE  URETER 


HENRY  MORRIS,  M.A.,  M.B.  Lond.,  F.R.C.S. 

SENIOR  SURGEON  TO  THE  MIDDLESEX  HOSPITAL  ;  EXAMINER  IN  SURGERY  IN  THE  UNIVERSITY  OF 
LONDON  ;  MEMBER  OF  THE  COUNCIL  AND  CHAIRMAN  OF  THE  COURT  OF  EXAMINERS  OF  THE 
ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND  ;  HUNTERIAN  PROFESSOR  OF  SURGERY  AND 
PATHOLOGY,  ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND  ;  HONORARY  MEMBER 
OF  THE  MEDICAL  SOCIETY  OF  THE  COUNTY  OF  NEW  YORK  ;  FORMERLY  LEC- 
TURER ON  SURGERY  AT  THE  MIDDLESEX  HOSPITAL  MEDICAL  SCHOOL 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO, 

IOI2     WALNUT     STREET 

1898 


PREFACE 


When  my  colleagues  in  the  Council  of  the  Royal  College 
of  Surgeons  did  me  the  honour  to  appoint  me  Hunterian 
Professor  of  Surgery  and  Pathology  for  the  year  1898, 1  had, 
in  the  first  place,  intended  to  give  my  personal  experience 
of  the  several  different  renal  affections  which  it  has  been  my 
lot  to  treat  surgically  during  the  seventeen  years  which  have 
elapsed  since  my  first  operation  of  nephrolithotomy.  But 
when  I  came  face  to  face  with  my  task  I  found  that  to  do  so 
would  necessitate  a  very  cursory  survey  of  a  considerable 
number  of  subjects. 

I  therefore  preferred  to  arrange  in  tabular  form  a  brief 
abstract  of  267  operations  which  I  have  performed  upon  the 
kidney  up  to  the  first  week  of  March  of  1898;  and  to  limit 
the  Lectures  themselves  to  calculous  disorders. 

I  have  also  collected  a  number  of  cases  in  which  opera- 
tions have  been  done  for  calculous  anuria,  and  have  devoted 
a  large  part  of  the  third  Lecture  to  that  subject ;  feeling — and 
I  believe  rightly — that  too  little  is  known  by  the  profession 
generally  about  this  form  of  anuria,  and  still  less  about  the 
advantages  which  the  surgical  treatment  of  it  affords. 

The  first  three  Lectures  and  the  Tables  were  prepared  for 
the  Hunterian  Lectures  ;  whilst  Lecture  four,  written  at  the 
same  'time  as  the  others,  was  published  in  the  Edinburgh 


vi  PREFACE. 

Medical  Journal  for  January  of  this  year ;  and  is  here  re- 
printed, revised,  and  with  additions. 

I  have  to  express  my  thanks  to  Dr.  W.  E.  Wynter  for 
valuable  assistance  in  searching  for,  and  verifying,  numerous 
references;  and  for  making  abstracts  from  several  foreign 
books  and  journals.  To  Dr.  H.  Campbell  Thomson  I  am 
indebted  for  the  great  labour  and  pains  he  bestowed  in 
tabulating  the  cases  from  my  private  and  hospital  note- 
books. To  Mr.  Berjeau  for  his  clever  drawings,  and  to 
Messrs.  Butterworth  for  their  skilful  and  careful  execution 
of  the  woodcuts  which  illustrate  these  Lectures,  my  best 
thanks  are  also  due. 


8,  Cavendish  Square,  W. 
October,  1898. 


CONTENTS, 


HUNTERIAN    LECTURE   I. 

PAGE 

On  the  Origin  and  Progress  of  Renal  Surgery  and  the 

Conservative  Tendency  of  its  Recent  Development  .       1 


HUNTERIAN    LECTURE   II. 


Renal  Calculus  :  The  Difficulties  and  Errors  in  Diag- 
nosis in  their  Relation  to  Exploration  of  the 
Kidney  :     Unsuspected,    Quiescent,    and    Migratory 

Calculi  ..........     44 


HUNTERIAN   LECTURE   III. 

Fistula  caused  by  Renal  Calculus  ;  Obstructive  Anuria 
due  to  Renal  Calculus  ;  The  Technique  of  the 
Exploration  of  the  Kidney  and  Ureter  for  Calculus     80 


LECTURE   IV. 

Injuries  of  the  Uretee        .......   l-!7 


viii  CONTENTS. 

HUNTEBIAN    LECTURES:    TABLES   OF   CASES 
OPERATED    UPON. 

PAGE 

TABLE     I.— Cases  of  Nephrolithotomy     .         .  .  .158 

,,         II. — Cases  op  Nephrotomy  for  Stone    .  .  .168 

,,       III. — Cases  of  Nephrectomy  for  Stone  .  .  .184 

,,       IV. — Exploratory  Operations          .         .  .  .192 

,,         V. — Operations  for  Movable  Kidney  .  .  .210 

,,       VI. — Hydronephrosis  and  Pyonephrosis  ,  .  232 

,,     VII. — Operations  for  Tuberculous  Disease  of  the 

Kidneys         .......  240 

„  VIII. — Nephrectomy  for  Fistula,  or  other  causes  .  254 

,,  IX. — Operations  for  Tumours  of  the  Kidney        .  258 

,,  X. — Operations  for  Injury    .....  266 

,,  XL — Collected  Cases  of  Calculous  Anuria  .         .270 


On  the  Origin  and  Progress 
of  Renal  Surgery. 


LECTURE    I. 

OX  THE  ORIGIN  AND  PROGRESS  OF  RENAL  SURGERY 
AND  THE  CONSERVATIVE  TENDENCY  OF  ITS 
RECENT   DEVELOPMENT. 

Me.  President  and  Gentlemen, — In  selecting  the  subject 
for  the  lectures,  which  by  the  grace  of  the  Council  I  am  about 
to  deliver,  I  was  influenced  by  the  fact  that  "  renal  surgery," 
though  it  has  attracted  a  good  deal  of  attention  amongst 
surgeons  during  the  last  twenty  years,  has  not  yet  received 
the  general  recognition  by  the  profession  at  large  to  which 
it  is  entitled ;  nor  has  it  hitherto  been  the  theme  of  any 
Hunterian  professor. 

I  propose  in  this  lecture  to  describe  briefly  the  origin,  and 
then  to  trace  the  progress,  of  this  quite  modern  branch  of 
surgery. 

HISTORY. 

In  the  sixteenth,  seventeenth,  and  eighteenth  centuries 
the  practicability  of  nephrotomy  was  repeatedly  discussed 
by  Camerarius  and  Francois  Rousset  in  1581 ;  by  Shenck 
in  1584  ;  Jean  Ducleclat  and  Cousinot  in  1622 ;  by  Riolan 
also  in  the  early  part  of  the  seventeenth  century;  by  Von 
Hilden  in  1646 ;  then  a  century  later  by  de  Lafitte*  in  1753, 
Borden  in  1754,  MM.  Hevin  and  Ledran  in  1757  ;  and  later 
still,  namely,  in  1829,  it  found  a  very  ardent  supporter  in 
P.  N.  Gerdy,f  the  professor  of  anatomy  and  surgery  in  Paris, 
who,  in  a  foot-note  to  his  lectures  on  anatomy,  to  artists, 
refers  at  considerable  length  to  the  subject  in  all  its  aspects. 

*  Lafitte :  "Surles  cas  ou  la  Nephrotomie  defait  avec  succes."  (Mem.  de 
l'Acad.  de  Chir.,  ed.  1819,  t.  ii.,  p.  235.) 

t  Gerdy,  P.  N. :  "  Anatomie  des  Formes  Exterieures  du  Corps  Humain." 
Paris  et  Bruxelles,  1829.  See  a  long  foot-note  on  pages  150,  151,  152,  153, 
and  154. 


2  HUNTERIAN  LEG  TUBES. 

As  regards  nephrectomy  various  physiological  experiments 
upon  animals  were  undertaken  by  Zambeccarius  *  about  the 
year  1670,  and  Roonhuyzenf  in  1672,  to  show  that  life  could 
be  well  maintained  after  removing  one  of  the  kidneys. 

BlancardJ  in  1690  expressed  the  opinion  that  extirpation 
of  the  kidney  would  give  a  fair  prospect  of  success  in  patients 
suffering  from  renal  calculi,  and  who  could  not  obtain  relief 
from  any  other  treatment. 

In  the  first  years  of  the  nineteenth  century  (1803)  Com- 
haire  §  was  repeating  the  experiments  of  Zambeccarius  with 
the  object  of  proving  that  nephrectomy  was  possible. 

Renal  incisions  are  said  to  have  been  practised  by  Cosse,  || 
by  Jean  Beverovicius  and  others,  upon  kidneys  greatly  dis- 
tended with  pus.  The  cases  of  the  archer  of  Meudon,  of  the 
British  consul  at  Venice,  and  others,  which  had  found  their 
way  into  surgical  literature,  may  be  dismissed  in  the  words  of 
M.  Hevin,U  who  wrote  in  the  year  1757,  "it  is  very  doubtful, 
if  not  absolutely  improbable,  that  cutting  into  the  kidney  had 
ever  been  practised  without  the  operation  having  been  deter- 
mined by  an  abscess  swelling;  or  by  a  fistula  due  to  renal  abscess 
which  had  broken  and  discharged  in  the  lumbar  region." 

None  of  these  cases  had  any  influence  whatever  in  encourag- 
ing surgeons  to  operate  upon  the  kidney  ;  and  no  surgical  treat- 
ment for  any  kind  of  renal  disease  was  systematically  emploj^ed 
until  the  second  half  of  the  present  century  had  well  advanced. 
As  M.  Le  Dentu  has  said,  it  needed  more  than  a  century  to 
overcome  the  interdiction  of  Hevin  against  incising  the  sound 
kidney.  An  interdiction  which  seemed  to  carry  with  it  the 
force  of  law. 

Nor  can  we  regard  the  cases  of  unintentional  excision  of 

*  Zambeccarius  :  "  Experimenta  circa  divers  var.  animal,  viv.  esset  vise,  et 
supplem."  (act.  nov.  erudit  Lipsiae),  sect.  6,  p.  275. 

t  Roonhuyzen:  "  Observ.  Chir.,"  part  i.,  obs.  22. 

%  Etienne  Blancard :  Article  Nephrotomia,  Lex.  Med.  Renovat.  et  Prax. 
Med.,  t.  ii.,  cap.  13,  pp.  252,  253. 

§  Comhaire :  "Dissertation  on  Extirpation  of  tbe  Kidney"  (These,  Paris, 
No.  85,  1803).     Roy.  Coll.  Surgeons'  Library. 

||  Cosse  dans  E.  Collot :    "  Traitc  de  TOperationdetaille." 

^f  Hevin;  "Researches,  Historical  and  Critical,  on  Nephrotomy  or  Cutting 
into  the  Kidney,"  1757.  (Mem.  de  l'Acad.  Roy.  de  Chirurgie,  t.  iii.,  part  2, 
sect.  2.) 


ORIGIN  AND  PROGRESS  OF  RENAL  SURGERY.         3 

the  kidney  (i.e.  diseased  kidneys  removed  on  a  wrong  diagnosis 
and  in  ignorance  of  the  nature  of  the  tumour  operated  upon) 
as  assisting  in  establishing  nephrectomy  as  a  recognised 
surgical  procedure. 

At  least  four  of  such  mistaken  operations  had  been  per- 
formed before  Simon's  first  nephrectomy ;  these  were  by 
Wolcott  in  1861,  Spiegelberg  in  1867,  Schnettelig  (Archiv  f. 
Gynecologic,  1871),  and  Peaslee  in  1868. 

All  were  followed  by  fatal  results,  and  for  this  reason 
would  not  have  been  encouraging  to  Simon,  even  if  he  had 
known  of  them,  which  intrinsically  it  is  not  probable  he  did. 

NEPHRECTOMY. 

The  dawn  of  renal  surgery  admittedly  dates  from  the 
2nd  of  August,  1869,  when  Gustav  Simon  of  Heidelberg  re- 
moved by  the  lumbar  method  the  kidney  of  a  woman 
who  had  a  ureteral  fistula  opening  upon  the  abdominal 
wall  above  the  pubes,  resulting  from  an  ovariotomy  done 
one  year  and  a  half  before.  Simon  performed  his  operation 
in  face  of  the  pronouncement  long  before  made  by  Rayer 
that  it  was  "  madness  to  dream  of  extirpating  a  kidney  in 
the  human  subject."  He  no  doubt  was  aware  of  the  ex- 
perimental results  of  Prevost  and  Dumas  (1823),  of  Claude 
Bernard,  Rayer,  Meissner,  and  Shephard,  all  of  whom  estab- 
lished the  fact  that  animals  could  live  with  only  one  kidney. 
For  himself,  he  compared  the  results  of  fifteen  hysterectomies 
with  fifteen  nephrectomies,  practised  on  animals,  and  was 
satisfied  that  there  was  no  more  danger  from  a  surgical  point 
of  view  in  the  one  operation  than  in  the  other ;  and  at  the 
same  time  he  convinced  himself  that  the  physiological 
changes  effected  by  the  kidneys  could  be  amply  performed 
by  one  after  the  ablation  of  the  other  organ.  The  cynic 
might  remark  that  the  same  fact  had  been  verified  over 
and  over  again  in  the  post-mortem  room  in  the  bodies  of 
persons  who  had  lived  with  one  kidney,  the  other  having 
been  absent  or  long  ago  atrophied ;  but  that  is  not  the  same 
fact.  What  was  wanted  was  the  assurance  that  one  kidney 
could  do  the  work  of  both,  after  the  shock  of  so  severe  an 
operation  as  nephrectomy. 

These   experiments   on   animals   led   Simon  to  resort  to 


4  I-WNTERJAN  LECTURES. 

nephrectomy  in  the  human  subject,  and  the  result  of  his 
first  operation  upon  woman  justified  his  deductions  drawn 
from  experiments  on  animals. 

Rather  more  than  a  year  after  Simon's  case,  Gilmore, 
in  America,  followed  (December,  1870)  with  a  very 
successful  nephrectomy  for  a  painful  shrunken  fibrous 
kidney  in  a  woman  five  months  pregnant,  and  who  re- 
covered without  a  miscarriage.  After  this  came  Simon's 
second  operation,  performed  in  August,  1871,  for  calculous  pye- 
litis, but  the  patient  died  of  pyaemia  on  the  twenty-first  day. 

Then  came  two  fatal  operations,  one  for  painful  kidney 
by  Durham,  and  the  other  for  calculous  pyelitis  by  Peters,  of 
New  York,  both  in  1872.  Next,  two  successful  ones  for 
injuries,  by  Brandt  in  1873,  and  Marvaud  in  1875.  Next, 
four  operations  for  malignant  disease,  two  successful,  namely, 
one  by  Langenbuch  in  1875,  and  one  by  Jessop,  of  Leeds,  in 

1877  ;  and  two  fatal,  both  by  Kocher,  in  1876  and  1877.     In 

1878  Martin  followed  with  four  successful  nephrectomies  for 
painful  floating  kidneys,  and  thus  confirmed  Simon's  first 
experience  and  Brandt's  result,  namely,  that  a  quite  healthy 
kidney  might  safely  be  removed. 

In  England  the  first  nephrectomy  was  performed  by 
Arthur  E.  Durham  on  May  14th,  1872.  The  next,  that  just 
referred  to  by  Jessop,  and  the  third  by  Barker. 

Barker,  who  had  made  himself  thoroughly  familiar  with 
Simon's  work,  read  two  important  papers  before  the  Royal 
Medical  and  Chirurgical  Society;  one  in  March,  1880,  the 
other  in  April,  1881.  He  therein  tabulated  all  the  nephrec- 
tomies done  up  to  those  dates,  and  thus  brought  the  whole 
subject  of  extirpation  of  the  kidney  before  the  notice  of 
British  surgeons,  who  till  then,  for  the  most  part,  were  quite 
unfamiliar  with  it. 

In  France,  where  the  earliest  and  most  ardent  advocates 
of  nephrotomy  had  lived,  nephrectomy  was,  for  several  years, 
either  neglected  or  opposed.  It  was  not  until  May  20th, 
1880,  nearly  eleven  years  after  Simon's  successful  initiative, 
that  M.  Leon  Le  Fort  practised  the  first  nephrectomy  done  in 
France.  This  was  performed  on  account  of  a  very  rare  form 
of  injury,  namely,  a  penetrating  wound  by  a  knife,  which 
completely  divided  the  ureter. 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.         5 
NEPHROTOMY. 

Nephrotomy  is  the  operation  which  had  received  most 
consideration  in  past  times,  especially  in  its  bearing  on  the 
treatment  of  renal  calculus  disorders ;  but  it  was  not,  in  all 
probability,  ever  systematically  put  into  practice  until  1870. 
Previous  to  1870  fluid  swellings,  believed  to  be  of  the  kidney, 
had  been  punctured,  and  opened  by  the  thermo-cautery ; 
and  perinephric  abscesses  had  been  incised  through  the 
loin. 

On  April  27th,  1869,  three  months  before  Gustav 
Simon's  first  nephrectomy,  a  paper  was  read  by  then  Mr., 
now  Sir,  Thomas  Smith,  describing  a  method  for  exposing 
the  kidney  through  the  loin.  This  he  recommended  for  diag- 
nostic purposes,  and  for  the  extraction  of  a  calculus,  if  of 
suitable  size  and  shape  and  capable  of  removal  through  the 
renal  pelvis ;  but  not  if  fixed  in  the  substance  of  the  kidney, 
or  if  its  removal  entailed  cutting  into  the  normal  secreting 
structure.  Though  the  author  had  no  actual  case  of  his  own 
to  record,  and  advocated  nothing  more  than  had  been  recom- 
mended on  several  occasions  during  the  two  preceding 
centuries,  there  can,  I  think,  be  little  doubt  that  his  paper, 
coming  when  it  did,  influenced  the  minds  of  surgeons  to  a 
degree  which  previous  similar  suggestions  had  failed  to  do. 
In  July  of  the  same  year  (1869)  Annandale,  and  in  January, 
1870,  Spencer  Wells  (Med.  Times  and  Gazette,  January  8th, 
1870).  also  wrote  in  favour  of  nephrotomy  in  some  cases  of 
renal  calculus.  These  articles,  together  with  Simon's  success, 
were  all  factors  leading  up  to  the  application  of  nephrotomy 
to  a  class  of  case  for  which  no  one  had  as  yet,  so  far  as  our 
absolute  knowledge  goes,  suggested  it ;  namely,  for  cases  of 
renal  calculus  in  a  kidney  otherwise  normal. 

In  1870,  Bryant  performed  nephrotomy  for  tuberculous 
pyonephrosis,  but  at  too  late  a  stage  to  save  his  patient ;  and 
in  the  same  year  Gunn  and  Durham  each  cut  down  upon  the 
kidney ;  and  Lente  and  Barbour  each  cut  into  the  kidney ; 
with  the  object  of  removing  calculi,  but  none  was  found.  All 
four  patients  recovered. 

During  the  next  ten  years,  1870 — 1880,  nephrotomy  was 
done    in    some   half-dozen   cases   (according    to   Dickinson's 


6  HUNTERIAN  LECTURES. 

tables*),  in  each  of  which  there  was  a  large  pyonephrosis, 
more  or  less  pointing  at  the  loin ;  and  in  four  of  these,  calculi 
were  extracted. 

NEPHROLITHOTOMY. 

No  further  advance,  however,  was  made  in  the  operative 
treatment  of  renal  disorders  till  February  11th,  1880,  when 
I  successfully  removed  a  mulberry  calculus  weighing  31  grs. 
from  the  undistended,  and  to  the  naked  eye  quite  normal, 
kidney  of  a  young  woman.  The  kidney  was  exposed  through 
an  oblique  lumbar  incision,  and  the  stone  reached  and  removed 
through  the  renal  parenchyma. 

At  that  time  I  was  unfamiliar  with  the  attempts  of  other 
surgeons  except  Durham,  whose  exploration  of  the  kidney, 
however,  was  not  a  nephrotomy  at  all.  Nor  did  I  then 
know  that  the  name  nephrolithotomy  which  I  suggested 
for  the  operation  I  had  performed  had  been  used  by  Hevin 
more  than  a  hundred  and  twenty  years  previously.  I  was  led 
to  undertake  the  operation  in  this  particular  case  by  the 
extreme  severity  and  persistency  of  the  symptoms,  and  by  the 
little  fear  I  felt  about  haemorrhage  from  the  cut  renal  paren- 
chyma, on  account  of  my  previous  experience  of  the  trivial 
and  easily  controlled  bleeding  from  the  cut  surface  of  the  liver 
in  operating  for  hydatid  tumours. 

This  case  demonstrated  for  the  first  time  that  a  stone  could 
be  removed  safely  by  cutting  freely  upon  it  through  a  thick 
layer  of  renal  tissue.  It  thus  became  the  starting  point 
of  both  the  development  and  the  conservatism  of  renal 
surgeiy,  which  I  am  persuaded  will  become  more  and 
more  conservative  in  the  future. 

The  second  nephrolithotomy  was  performed  in  August, 
18S1,  by  the  late  Mr.  Marcus  Beck,  who  removed  a  calculus 
composed  of  uric  acid  and  phosphates  weighing  26  grs.  through 
an  incision  in  the  renal  substance.  Then  followed  cases  by 
Mr.  Butlin,  who  extracted  an  oxalate  of  lime  calculus  weighing1 
60  grs.  by  scratching  through  the  renal  pelvis ;  by  Mr.  Bennett 
May,  by  myself,  and  other  surgeons ;  and  in  the  list  of  my 
operations  for  removal  of  renal  calculus  by  nephrolithotomy 
I  am  able  to  show  thirty- four  operations  with  thirty-three 
recoveries    and    one    death.      These    results     disprove    the 

*  "  On  Renal  and  Urinary  Affections,"  vol.  Hi.,  pp.  984  et  seq.,  1S85. 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.  7 

supposed  dangers  of  nephrolithotomy,  and  show  the  invalidity 
of  the  objections  which  in  all  previous  times  had  been  urged 
against  the  proposal  to  operate  upon  a  kidney  not  already 
converted  into  a  mere  abscess  sac. 

NEPHROPEXY. 

Fourteen  months  after  the  first  nephrolithotomy  Halm 
of  Berlin  introduced  an  operation  at  first  called  nephror- 
rhaphy  and  afterwards,  by  the  French  writers,  nephropexy. 
for  fixing  movable  kidneys.  This  consisted  in  an  incision 
alongside  the  sacro-lumbalis  muscle  (such  as  the  old  writers 
advised  for  nephrotomy  and  Simon  had  employed  for 
nephrectomy)  extending  from  the  twelfth  rib  to  the  crest  of 
the  ilium.  The  quadratus  lumborum  was  cut ;  and  the  fibro- 
fatty  capsule  was  opened  along  the  outer  border  of  the  kidney, 
and  having  been  separated  to  some  extent  was  dragged 
forcibly  backwards  into  the  wound  along  with  the  kidne}'. 
By  means  of  six  or  eight  catgut  sutures  this  capsule  was 
stitched  into  the  wound,  and  the  wound  itself  plugged  with 
carbolic  gauze. 

In  his  account,  published  in  July,  1881,  Hahn  describes 
two  cases  thus  operated  upon  by  himself  in  April  of  that  year. 
The  patients  were  both  women,  and  recovered  in  four  weeks 
with  the  kidneys  as  securely  in  their  attached  position  as 
immediately  after  the  operation. 

This  was  an  important  advance,  because  it  at  once  had  the 
effect  of  putting  a  stop  to  nephrectomy  for  movable  kidney 
which  had  been  recommended  and  practised  by  Martin  of 
Berlin  in  1878.  The  importance  of  this  step  was  indeed  great, 
for  it  not  only  brought  about  the  substitution  of  a  safe  opera- 
tion for  one  which,  at  that  time  especially,  was  attended  with 
a  very  high  mortality,  but  it  also  saved  healthy  organs  from 
being  needlessly  excised,  and  was  applicable  to  both  kidneys  of 
the  same  person  when  both  were  movable  and  required  fixing. 

But  Hahn's  method  had  this  drawback,  that  it  was  not 
always  or  permanently  efficacious;  whereas,  of  course,  nephrec- 
tomy, though  only  capable  of  being  employed  for  one  kidney 
could  not  be  followed  by  a  return  of  symptoms. 

The  principle  of  Hahn's  operation  was  perfect ;  what  was 
wanted  was  the  improvement  of  the  technique.     I  never  felt 


8  HUNTERIAN  LECTURES. 

confidence  in  this  mode  of  fixation,  and  preferred  to  attach 
the  kidney  itself  to  the  cut  edges  of  the  transversalis  fascia 
and  the  aponeurosis  of  the  transversalis  muscle  by  means 
of  three  sutures  dipped  deeply  into  the  posterior  surface  of 
the  organ  and  running  for  from  three-quarters  of  an  inch  to 
an  inch  in  its  substance.  I  have  used  various  materials  for 
sutures — stout  catsfut,  kangaroo  tendon,  and  silk,  but  now 
always  employ  fine  silk.  The  accompanying  figure  will 
explain  my  method  of  inserting  the  sutures. 


Fig.  1. — Author's  method  of  fixing  kidney.      Left  kidney  shown. 

The  results  obtained  have  in  most  of  the  cases  been 
perfectly  satisfactory,  and  I  see  from  time  to  time  patients 
upon  whom  I  operated  nine  or  ten  years  ago  with  their 
kidneys  as  firmly  fixed  as  can  be  desired,  and  who  have  been 
quite  free  of  their  former  symptoms  ever  since  the  operation. 
Moreover,  I  have  had  the  opportunity  of  witnessing  in  the 
living  bodies  of  some  three  or  four  of  my  patients  the  sound 
and  complete  holdfast  which  this  method  affords.  It  has 
a  few  times  happened  to  me  from  six  to  twelve  months  or 
longer  after  fixing  a  hydronephrotic  as  well  as  after  fixing  the 
healthy  kidney,  to  have  to  do  a  second  operation  for  quite 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.         9 

different  reasons  upon  the  same  organ  :  and  I  have  then  seen 
my  sutures  embedded  in  a  mass  of  tough  fibrous  tissue,  and 
have  had  to  pull  or  cut  them  out  from  the  renal  parenchyma 
before  I  could  detach  the  kidney.  Here  they  had  for  months 
harmlessly  remained  Avithout  showing  the  least  tendency  to 
become  the  nuclei  of  calculi,  as  some  surgeons  anticipated 
would  be  the  case. 

M.  Tuffier  of  Paris,  whose  admirable  experimental  work, 
published  in  1889,  on  this  and  other  branches  of  renal  and 
ureteral  surgery  is  well  known,  is  of  opinion  that  the  paren- 
chyma where  the  sutures  constrict  it,  becomes  sclerosed  and 
atrophied.  This  condition  did  not  appear  to  have  been  caused 
in  the  kidneys  of  the  cases  just  referred  to  ;  but  even  if  it 
had  been,  the  amount  of  the  kidney  tissue  so  affected  would 
be  small,  and  could  easily  be  spared  without  danger  to  the 
individual.  Moreover,  it  would  be  less  extensive  than  the 
superficial  sclerosis  which  follows  the  plan  which  M.  Tuffier 
himself  advocates. 

Tuffier,  believing  that  the  proper  capsule  of  the  kidney 
— smooth,  thin,  little  resisting,  avascular,  and  fibrous  as  it  is — 
prevents  the  kidney  itself  from  forming  firm  adhesions  with 
the  tissues  and  organs  around  it,  recommends  its  partial  decor- 
tication, and  the  suturing  of  the  tunica  propria  to  the  edges 
of  the  parietal  wound.  This  done,  he  thinks  the  parenchyma 
does  not  fail  to  attach  itself  firmly  to  the  neighbouring  tissues 
by  the  whole  of  the  exposed  area.  The  figures  show  two 
different  ways  by  which  he  accomplishes  this.  Various 
modifications  of  Turner's  method  have  been  practised  by 
different  surgeons,  but  the  principle  of  them  all  is  to  obtain 
direct  adhesion  between  the  bared  parenchyma  and  the  deep 
tissues  of  the  abdominal  wall ;  whether  the  capsule  is  de- 
tached in  small  squares,  or  in  one  large  piece,  or  in  many 
triangular  slips,  or  is  merely  scarified. 

A  fourth  method  has  more  recently  been  suggested  by 
M.  Vulliet*  of  Geneva,  and  was  first  tried  by  his  friend  Poullet 
of  Lyons.  It  consists  in  making  use  of  a  long  slender  slip  of 
the  tendon  of  the  erector  spinas  of  the  patient,  as  the  means 
of  fixation  of  the  kidney.      After  exposing  and   freeing  the 

*    Vulliet:    "D'une  nouvelle  operation  de  nephropexie  "  (Revue  Mvdicale  de 
la  Suisse  Romande,  20  Juin,  1895,  pp.  326  et  seq.). 


10 


HUNTER! AN  LECTURES. 


kidney  in  the  usual  manner,  a  separate  short  vertical  in- 
cision, parallel  with  the  spinous  process  of  the  first  lumbar 
vertebra,  is  made  through  skin  and  fascia,  and  a  tape-like 
slip  of  the  tendon,  about  ten  inches  long  and  a  quarter  of 
an  inch  wide,  is  detached  and  pulled  out  through  this  little 
wound,  but  still  left  attached  by  its  lower  end  to  the  muscle. 
This  tendinous  slip  is  to  be  the  suture,  and  is  passed  through 
the  muscular  tissue,  and  havinsr  been  made  to  underrun 
the  capsule  of  the  kidney,  is  then  passed  back  again  and 
fixed  to  the  erector  spinas  muscle.  This  is  shown  in  the 
accompanying  figure. 


Last  rib. 


Deflected  tendon  slip,  showing  its 
course  through  the  muscular  mass 
and  beneath  the   renal  capsule. 

Spinous  process  tirst 
lumbar  vertebra. 

Muscular  mass. 


Fig-  2.—  Vulliet's  method  of  fixing  kidney. 


I  have  in  some  cases  practised  Turner's  and,  in  others, 
Vulliet's  method,  but  have  found  it  requisite  to  modify  the 
latter,  because  in  many  cases  too  short  a  length  of  the  tendon 
is  torn  out.  This  modification  consists  in  splitting  the  width 
of  the  detached  tendon  and  passing  each  half  separately 
through  the  torn  muscles  clown  to  the  kidney.  Having  under- 
run  the  kidney  with  one  length  of  the  tendon  this  length  is 
then  tightly  tied  to  the  other  length.  The  kidney  is  thus 
slung  by  the  tendon,  the  split  ends  of  which  may,  if  desired,  be 
passed  back  through  the  torn  muscles  and  fixed  to  the  sheath 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.       11 

of  the  erector  spinas.  I  prefer  Vulliet's  method  to  Turner's, 
but  that  neither  is  so  simple,  or  so  rapidly  done,  or  more 
efficacious  than  my  own. 

PARTIAL   EXCISIONS. 

Another  most  important  advance  in  the  conservatism  of 
the  surgery  of  the  kidney  is  the  excision  of  diseased  por- 
tions of  the  organ  in  place  of  nephrectomy.  This  step  was 
a  natural  result  of  the  establishment  of  nephrolithotomy  as 
a  sound  surgical  procedure.  The  fear  of  uncontrollable 
bleeding  during  the  operation,  and  the  doubts  as  to  the 
healing  power  of  a  kidney  when  cut  into  or  otherwise  wounded 
being  once  removed,  the  attempt  to  save  the  greater  part 
of  the  organ,  when  only  a  small  portion  was  diseased  or 
injured,  was  bound  to  be  made. 

Turner's  experiments  on  animals  in  1888,  and  Barth's 
histological  researches,  supply  ample  proofs  of  the  healing- 
power  of  the  kidney,  and  of  the  process  by  which  this 
healing  is  accomplished,  even  after  extirpation  of  consider- 
able portions.  Paoli*  of  Perugia  performed  extraperitoneal 
operations  for  resection  of  the  kidney  upon  twenty-five  dogs, 
cats,  and  rabbits,  with  perfect  recovery,  and  published  his 
results  in  1890. 

But  such  experiments  were  not  required  to  convince  us 
that  wounds  of  the  human  kidney  readily  heal.  In 
1883  and  1884  I  collected  for  my  work  on  diseases  of  the 
kidney  a  number  of  cases,  proving  the  cicatrising  capacity 
of  the  human  kidney  after  incised,  punctured,  lacerated,  and 
also  gunshot  wounds.  Such  cases,  known  long  before  the 
days  of  renal  operations,  might  have  given  surgeons  faith  in 
the  reparative  power  of  renal  wounds  of  their  own  making, 
but  it  has  been  only  by  slow  degrees,  and  quite  recently, 
that  they  have  become  convinced  that  a  free  incision  or  a 
partial  excision  may  be  made  without  fear  of  dangerous 
bleeding  on  the  one  hand,  or  of  an  urinary  fistula  following 
the  operation  on  the  other  hand. 

In  1890  I  had  the  opportunity  of  examining  a  kidney 
which  I  had  freely  incised  for  exploratory  purposes  a  month 
before,  and  which  was  removed  from  the  body  of  a  patient 

*  "Verh.des  Internal.  Med.  Cong.,  Berlin,  1890." 


12  HUNTERIAX   LECTURES. 

who  died  from  haemorrhage  from  a  gastric  ulcer.  A  linear 
scar  extending  through  the  cortex  to  the  renal  pelvis  was  the 
only  evidence  in  the  organ  that  an  operation  had  been  per- 
formed upon  it.  The  kidney  otherwise  had  the  appearance 
of  being  perfectly  healthy. 

Up  to  the  present  time  partial  excision  or  resection  has 
been  very  rarely  performed ;  and  surgeons,  whether  aware 
of  the  results  of  such  experiments  as  Tuffler's  and  others,  or 
not,  seem  to  hesitate  to  apply  the  method  in  man. 

An  excellent  epitome  of  the  work  hitherto  done  in  this 
direction  is  contained  in  a  paper  read  before  the  British 
Medical  Association  at  Carlisle  in  1896  by  Oscar  Bloch  of 
Copenhagen.  He  therein  reports  a  case  in  which  he  removed, 
in  September,  1895,  half  the  kidney  affected  by  a  new 
growth  ;  and  gives  abstracts  of  ten  cases  which  he  collected 
from  German  and  French  sources.  The  first  partial  excision 
was  by  Czerny  in  November,  1887,  for  an  angeio-sarcoma 
following  injury.  Tuffier  has  operated  in  three  cases ;  in  his 
first  case,  which  was  done  in  1889,  he  cut  out  a  fistulous  canal 
and  sutured  the  cut  surfaces  of  the  kidney  together ;  the 
wound  healed  by  first  intention.  Kvimmell  has  operated  also 
in  three  cases,  Bardenheuer  in  two,  and  Waitz  in  one. 

Three  out  of  the  eleven  operations  were  for  cysts,  of  which 
one  was  hydatid ;  three  were  for  calculous  pyonephritis ; 
two  were  for  new  growths,  and  one  each  for  puerperal 
pyonephritis,  renal  fistula,  and  a  patch  of  interstitial 
nephritis  mistaken  for  malignant  growth.  Not  one  of  these 
eleven  patients  died  from  the  operation.  Nine  of  them  made 
good  recoveries  therefrom,  one  subsequently  required 
nephrectomy,  and  in  one  a  fistula  resulted. 

Bloch  makes  no  mention  of  any  English  or  American  cases. 
My  own  experience  of  resection  commenced  in  November, 
1890  (Table  VII.,  No.  6),  Avhen,  in  drawing  out  a  kidney  of  a 
young  man,  aged  twenty-four,  which  I  was  exploring  for 
calculus,  several  abscesses  were  seen  in  the  cortex,  which  I 
opened  and  evacuated  and  scraped.  The  kidney  was  re- 
placed and  the  loin  wound  closed,  but  a  week  later  I  had 
to  remove  the  whole  kidney  on  account  of  acute  general 
pyonephritis.  The  man  quite  recovered  after  a  long  conva- 
lescence, and  is  well,  and  leading  an  active  life  to-day. 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.       13 

In  April,  1892  (British  Med.  Jour  a.,  1892,  vol.  i.,  p.  899), 
I  scraped  out  six  tuberculous,  breaking  down  caseous  masses 
in  the  kidney  of  a  man  aged  twenty-eight,  which  I  was 
exploring  for  calculus.  The  raw  surfaces  of  the  kidney 
from  which  these  deposits  were  removed  were  treated  freely 
with  iodoform  emulsion ;  the  kidney  was  then  put  back  into 
position  and  the  lumbar  wound  closed.  An  excellent  re- 
covery followed,  but  some  tAvo  years  afterwards  he  returned 
with  tuberculous  disease  of  one  of  the  testes,  but  no  further 
trouble  in  the  kidney  ;  the  testicle  also  was  treated  by  incision 
and  erasion,  and  he  again  recovered  (Table  VII.,  No.  8). 

In  a  third  case,  that  of  a  female  aged  twenty-eight,  whose 
left  kidney  I  was  exploring  for  stone,  on  January  2nd,  1895, 
I  found  three  areas  of  grouped  miliary  tubercles  at  different 
points  of  the  kidney.  I  removed  them  by  excising  three 
wedges  of  the  renal  parenchyma,  and  in  so  doing  opened  up 
the  calyces.  At  one  of  these  wounds  I  shaved  off:'  layer  after 
layer  till  I  reached  healthy  kidney  tissue.  rlhe  cut  surfaces 
were  sutured  with  catgut,  three  sutures  in  each  wound.  The 
kidney  was  then  replaced,  and  the  parietal  wound  closed. 
After  the  operation  blood  was  passed  with  the  urine  for  three 
days.  The  patient  made  a  rapid  recovery,  and  left  the  home 
without  a  sinus  on  January  16th,  1895.  In  March,  1897,  two 
years  and  two  months  afterwards,  her  husband  wrote  stating 
that  she  had  steadily  improved  in  health  since  the  operation, 
and  was  then  well  (Table  VII,  No.  16). 

In  three  other  cases  I  have  done  similar  operations  on 
women.  In  one  of  them  quite  a  third  of  the  kidney  was 
removed  for  tuberculous  disease.  All  recovered  from  the 
operations.  One,  a  woman,  aged  forty-five,  from  whom  I  re- 
moved an  abscess  in  the  renal  parenchyma,  recovered,  but 
symptoms  have  recurred  since  (Table  IV.,  No.  41).  One  from 
whose  right  kidney  I  excised  a  cyst  and  a  tuberculous 
abscess,  lived  three  years  afterwards  without  a  fistula  or  any 
return  of  trouble  in  this  kidney  (see  Table  VII.,  No.  14),  and 
died  of  an  acute  attack  of  broncho-pneumonia  in  1897.  The 
third,  from  whose  left  kidney  I  removed  quite  a  considerable 
portion  for  tuberculous  disease,  recovered  without  a  fistula, 
but  seven  months  afterwards  an  abscess  formed  in  the  iliac 
fossa  of  the  same  side  and  opened  at  the  scar.     The  kidney 


U  HUN  TEE  IAN  LECTURES. 

and  a  great  part  of  the  ureter  were  subsequently  removed, 
as  it  was  thought  they  were  the  cause  of  the  abscess,  but  this 
was  not  so,  although  the  kidney  was  considerably  diseased 
(see  Table  VII.,  Nos.  22  and  28).  She  subsequently  had 
severe  haemoptysis,  and  died  of  tuberculous  disease  of  the 
lung  and  peritoneum,  and  a  tuberculous  ulcer  in  the  bladder. 

Partial  resections  are  capable  of  a  wider  application  than 
has  yet  been  given  to  the  operation,  especially  in  the  case  of 
tumours  taking  origin  from  the  renal  capsule,  and  those  which 
though  originating  in  the  perinephric  tissue,  grow  into,  and 
partially  destroy  the  kidney  itself. 

In  an  operation  upon  an  elderly  woman  in  1896  I 
endeavoured  to  save  the  kidney  when  removing  a  large 
perinephric  fibro-lipoma,  but  in  the  course  of  the  operation  I 
found  it  impossible  to  do  so.  If  in  future  such  tumours  are 
operated  upon  before  they  attain  so  large  a  size  as  practically 
to  destroy  or  surround  the  kidney,  there  is  no  reason  why 
they  should  not  be  removed  without  interfering  with  the 
kidney,  or  at  any  rate  without  excising  more  than  a  small 
portion  instead  of  the  whole  of  the  organ. 

Besides  the  cysts  which  project  from  the  parenchyma  and 
the  morbid  conditions  of  the  cortex  which  have  been  referred 
to,  it  is  reasonable  to  anticipate  that  innocent  tumours,  such 
as  villous  papilloma  will  be  successfully  removed  from  the 
renal  pelvis  without  sacrificing  the  whole  organ  by  nephrec- 
tomy. Some  of  the  few  specimens  of  this  disease  which  are  in 
our  museums  would  have  been  quite  amenable  to  this  treat- 
ment. Bardenheuer  and,  in  this  country,  E.  Owen  and  Keetley, 
acting  on  the  same  conservative  principle,  have  treated  cases 
of  accidental  injuries  of  the  kidneys  by  taking  away  a  portion 
and  leaving  the  bulk  of  the  organ.  Dr.  Nash,  of  Wallsend, 
N.S.W.,  in  June,  1897,  removed  from  a  youth,  set.  eighteen 
years,  a  portion  of  the  kidney  and  kidney  capsule  which  had 
been  broken  off  from  the  rest  of  the  organ  by  a  kick  from  a 
horse.  The  portion  of  the  kidney  left  consisted  of  about  five- 
eighths  of  the  whole  organ ;  it  lay  in  its  proper  place,  with 
a  clean  cut  incision  passing  from  before  backwards  at  the 
level  of  the  upper  end  of  the  renal  pelvis.  The  operation 
was  done  one  week  after  the  injury.  The  patient  made  a  good 
recovery  (Australasian  Medical  Gazette,  Nov.  20th,  1897). 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.        15 
OPERATIONS   ON   THE   URETER. 

Operations  upon  the  ureter  are  an  advance  of  the  last 
few  years,  but  not  many  have  been  recorded  up  to  the 
present  time. 

They  are  ot  very  considerable  importance  because  of  the 
influence  they  are  having,  and  are  destined  to  have,  upon 
renal  surgery  generally. 

Ureterotomy  has  been  employed  in  the  treatment  of 
hydronephrosis,  calculus,  and  calculous  anuria.  Ureterectomy 
will  improve  the  results  of  operations  for  advanced  tuberculous 
disease  descending  from  the  kidney,  and  also  of  those  per- 
formed for  calculous  pyonephrosis  complicated  with  sup- 
purative ureteritis.  Ureteral  anastomosis  and  other  plastic 
operations  on  the  ureter  will  save  many  kidneys  which  would 
formerly  have  been  nephrectonised  on  account  of  hydro- 
nephrosis, fistula?,  and  surgical  injuries  of  the  ureter. 

It  is  of  interest  to  note  that  ureterotomy,  like  nephrotomy 
and  nephrolithotomy,  was  suggested  many  years  before  it  was 
put  into  practice.  The  first  allusion  to  it  which  I  have  met 
with  is  in  Velpeau's  Surgery  (edition  1851,  p.  1021). 
Velpeau  mentions  it  in  connection  with  an  account  of  a  case 
under  his  own  care,  in  which  a  calculus  the  size  of  a  nut,  and 
having  a  pin  in  its  centre,  Avas  impacted  in  the  right  ureter 
three  inches  below-  the  kidney.  The  posterior  wall  of  the 
ureter  was  perforated  at  the  level  of  the  calculus,  and  there 
was  (periureteral)  suppuration  in  the  retroperitoneal  tissue, 
extending  from  the  kidney  to  the  floor  of  the  pelvis.  Velpeau 
satisfied  himself  upon  the  dead  body  that  this  stone  might 
have  been  readily  extracted  by  the  flank  on  the  same  side. 

In  1856  a  remarkable  series  of  articles  was  published  by 
Dr.  C.  Gigon  of  Angouleme  (L' Union  Medicate,  Feb.  14th, 
16th,  21st,  1856),  in  which  he  suggested  opening  the  ureter 
with  the  object  of  establishing  an  artificial  passage  for 
the  escape  of  urine  in  a  case  of  calculous  anuria.  He 
called  the  operation  he  proposed  ureterotomy,  investigated 
the  anatomical  causes  which  determine  the  impaction  of 
calculus  in  the  ureter,  gave  an  excellent  description  of  the 
normal  anatomy,  and  figured  the  natural  dilatations  and 
contractions  in  the  lumen  of  the  ureter.     He  pointed  out  the 


16  HTJNTERIAN  LECTURES. 

intimate  relation  of  the  ureter  with  the  peritoneum,  and  that 
it  is  the  peritoneum  which  maintains  the  ureter  in  contact 
with  the  psoas  magnus.  This  led  him  to  explain  the  rationale 
of  enforced  walking  exercise  upon  a  calculus  impacted  in  the 
ureter ;  the  contraction  of  the  fibres  of  the  psoas,  he  thought 
communicated  to  the  ureter  a  sort  of  peristaltic  action  which 
made  the  stone  descend  towards  the  bladder. 

He  gave  the  explanation  based  on  his  anatomical  know- 
ledge, and  upon  a  post-mortem  examination  of  a  case  in  which 
he  found  a  movable  right  kidney  opposite  the  third  and  fourth 
lumbar  vertebra?,  of  the  occurrence  of  hydronephrosis  in  asso- 
ciation with  movable  kidney.  This,  be  it  observed,  was 
forty-two  years  before  the  same  explanation  was  credited  to 
Lanclau,  Terrier,  and  Baudoin  respectively.  He  attributed  it  to 
kinking  of  the  ureter,  which,  fixed  by  the  peritoneum,  cannot 
follow  the  kidney  in  its  displacements,  and  thus  causes  it 
to  form  a  curve  with  the  convexity  upwards,  all  the  more 
pronounced  as  the  kidney  gets  lower  and  lower.  The  result 
of  this  curvature,  he  thought,  was  to  obstruct  the  urine,  or 
even  to  render  its  flow  impossible.  Finally,  he  described  the 
operations  of  ureterotomy  and  lumbar  ureterostomy  precisely 
as  they  are  now  performed.  Gigon  thought  that  the  obstruc- 
tion to  the  free  flow  of  urine  due  to  the  kinking  of  the 
ureter  was  a  predisposing  cause  of  stone  in  movable  kidneys, 
and  in  support  of  this  view,  I  ma}*-  say  that  I  have  seen 
several  instances  of  very  movable  kidneys  which  contained 
calculi ;  as  well  as  cases  in  which  the  kidneys  have  been 
greatly  disorganised  from  stone,  with  the  ureters  strictured 
or  of  very  small  size,  and  thus  giving  rise  to  more  or  less 
obstruction.  Fig.  3  is  an  illustration  of  a  small  ureter  and 
a  stone  impacted  immediately  above  it. 

Ureterotomy  for  Calculus. — In  1879  Thomas  Addis 
Emmet  of  New  York  (in  the  edition  of  his  work  on  the 
"Principles  and  Practice  of  Gynaecology,"  published  in  1879) 
stated  that  in  three  cases  he  had  met  with  stones  obstruct- 
ing the  vesical  end  of  the  ureters.  In  one  he  removed  the 
stone  through  the  bladder  by  means  of  curette  forceps  after 
opening  the  bladder.  In  the  second  case  he  removed  a  stone 
weighing  98  grs.  by  cutting  upon  it  through  the  vaginal 
wall  without  having  opened  either  the  bladder  or  the  peri- 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY. 


17 


tbn.eu.in,  and  he  closed  the  opening  Avith  interrupted  sutures. 
His  third  case  does  not  seem  to  have  been  operated  upon. 

It  was  not,  however,  until  the  }^ear  after  Harm's  first 
nephrorrhaphy  that  ureteral  surgery  fairly  commenced.  In 
1882     Bardenheuer    performed    ureterotomy    for    calculous 


Fig.  3. — Small  ureter  with  contractions  of  its  lumen.  A  stone  plugs  the  infundibu- 
lum,  and  the  kidney  is  completely  disorganised.  (Author's  case.  Table  III., 
No.  15). 

anuria,  removed  four  stones,  one  of  which  was  impacted  in 
the  upper  end  of  the  ureter,  and  closed  the  ureteral  incision 
by  sutures.  In  Bardenheuer's  case  the  urine  did  not  find  its 
way  subsequently  into  the  bladder,  so  he  divided  the  ureter 
and  established  a  lumbar  ureterostomy. 

In  1884  I  published  a  paper  advocating  the  extraction  of 
calculi   impacted   in   the   intra-vesical  portion  of  the  ureter 
c 


18  HUN TE MAN  LEG  TUBES. 

through  the  bladder,  by  opening  the  bladder  from  the  perineum 
in  the  male,  and  by  dilating  the  urethra  in  the  female  ;  and  I 
suggested  that  this  might  be  found  useful  in  cases  of  calculous 
anuria,  and  might  obviate  the  performance  of  nephrectomy  in 
certain  cases  of  calculous  hydronephrosis.  I  therein  related  a 
case  of  calculous  anuria,  in  which,  by  scratching  through  the 
margin  of  the  vesical  orifice  of  the  ureter  with  my  finger-nail, 
I  tried  to  get  a  calculus  into  the  bladder  and  thence  remove  it 
through  the  urethra  (Amer.  Joum.  Med.  Sciences,  Oct., 
1884,  p.  455). 

In  1885  Cullingworth  removed  a  calculus  from  the  lower 
end  of  the  ureter  of  a  woman,  by  abdominal  section.  In  this 
case  stones  could  be  felt  per  vaginam  in  both  ureters.  The 
operation  was  designed  and  undertaken  for  abdominal  nephrec- 
tomy. The  right  kidney  formed  a  large  tumour,  but  a  stone 
being  found  in  the  right  ureter  this  was  removed  instead. 
Death  followed  from  uraemia. 

In  1887  Ceci  (La  Riforma  Medicate,  September  5th,  1887) 
removed  seven  calculi  from  the  lower  end  of  the  ureter  by  an 
incision  through  the  rectum.     The  patient,  however,  died. 

In  1887  ureterotomy  was  performed,  and  has  since  been  re- 
peated in  several  cases,  for  the  extraction  of  calculi  impacted 
in  different  parts  of  the  ureter  by  means  of  a  retroperitoneal 
operation  in  the  lumbar  or  inguino-lumbar  region,  by  Godlee 
in  1887,  by  Kirkham  and  Torrey  in  1889,  by  Twynam  in 
1890,  and  by  several  other  surgeons  more  recently. 

Ureterotomy  for  stricture  and  valvular  obstruction. 
— Another  application  of  ureterotomy  is  in  cases  of  ureteral 
stenosis.  Simon  in  1876  was  the  first  to  give  theoretical 
directions  for  this  operation.  I  do  not  know  that  he  ever 
performed  it.  Trendelenburg  in  1890  was,  I  believe,  the  first 
to  make  the  attempt. 

In  1892  Fenger  of  Chicago  performed  the  first  successful 
ureterotomy  for  a  valvular  obstruction  of  the  ureter.  (Trans. 
Amer.  Surg.  Assoc,  1894,  vol.  xii.,  p.  142.)  The  patient 
was  a  woman  aged  twenty-eight,  with  intermittent  hydro- 
nephrosis in  a  floating  kidney.  He  explored  the  dilated  renal 
calyces  for  stone  through  an  incision  in  the  convex  border 
of  the  kidney.  No  stone  was  present.  As  he  could  not 
catheterise  the  ureter  through  this  incision,  he  made  a  small 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        1!) 

opening  in  the  posterior  wall  of  the  infundibulum,  and  found 
a  valvular  obstruction  at  the  top  of  the  ureter  where  it  joined 
the  renal  pelvis.  The  valve  was  divided,  and  the  ends  of  the 
incision  were  united  by  a  suture.  A  bougie,  now  passed 
through  the  wound  in  the  parenchyma,  was  retained  in  the 
ureter  for  two  days.  The  wound  in  the  renal  pelvis  was  closed 
by  sutures.  The  floating  kidney  was  fixed.  The  patient 
recovered  without  fistula,  and  subsequently  had  no  return 
of  hydronephrosis. 

On  November  26th  of*  the  same  year  (1892)  Fenger 
operated  upon  a  man  aged  forty-seven  for  intermittent 
hydronephrosis  of  twenty  years'  duration,  due  to  a  stricture 
of  the  ureter  close  to  its  junction  with  the  infundibulum. 

The  stricture  was  produced  by  an  injury  when  the  patient 
was  thirteen  years  old  by  his  jumping  from  the  back  of  a  horse. 
The  kidney  and  upper  end  of  the  ureter  were  exposed 
through  a  lumbar  incision,  The  upper  end  of  the  ureter 
for  half  an  inch  was  found  imbedded  in  cicatricial  tissue  ; 
below  this  the  ureter  was  normal.  A  longitudinal  incision, 
a  centimetre  long,  was  made  into  the  ureter  just  below  the 
cicatrix,  and  the  strictured  part  of  the  tube  was  divided  from 
below  upwards  to  the  renal  pelvis.  The  ends  of  the  incision 
in  the  ureter  were  stitched  together  by  the  Heinecke-Mikulicz 
manner  for  closing  the  pylorus  after  division  for  stenosis. 

The  next  successful  operation  of  this  sort  was  performed 
by  Herman  Mynter  of  Buffalo,  on  August  14th,  1893.  The 
patient  was  a  man  aged  twenty-five,  who  for  twelve  years 
had  suffered  from  painful  intermittent  hydronephrosis,  due 
to  a  valvular  obstruction  at  the  upper  extremity  of  the  ureter. 
Calculus  was  diagnosed  as  the  cause  of  the  obstruction,  but 
no  stone  was  found.  On  exposing  the  kidney  and  upper  part 
of  the  ureter  through  the  "  usual  oblique  incision  "  in  the 
loin,  a  valve  formation  at  the  junction  of  the  ureter  and  renal 
pelvis,  and  a  hydronephrotic  distension  of  the  infundibulum 
of  the  size  of  an  orange,  were  discovered.  An  incision  an 
inch  long  was  made  into  the  lower  part  of  this  swelling,  and 
about  half  a  pint  of  pale  limpid  urine  evacuated.  Through 
this  opening  in  the  infundibulum  the  kidney  and  ureter  were 
explored.  The  incision  was  then  prolonged  downwards 
through   the   valvular   stricture,  the  lateral  margins  of  the 


20 


HVNTERIAN  LEG  TUBES. 


wound  were  pulled  apart,  and  the  ends  united  by  numerous 
fine  silk  sutures,  avoiding  the  mucous  membrane.  After  the 
wound  was  sutured,  the  opening  into  the  ureter  from  the 
renal  pelvis  was  somewhat  funnel-shaped.  The  patient 
recovered  without  a  fistula,  and  remained  well  subsequently. 

I  have  recently  done  a  similar  operation  on  a  female 
patient,  aged  twenty-nine,  who  for  four  or  five  months  had 
had    intermittent   periods   of    aching   or   discomfort   in   the 


Fig.  4. — Pelvis  of  the  kidney  and  upper  end  of  ureter,  showing  the  stricture  at  then- 
junction.  A  probe  has  been  passed  along  the  ureter  through  an  opening  in  the 
infundibulum.     (Author's  case.     Table  VI.,  No.  19.) 

right  kidney  (which  was  very  movable),  associated  with  very 
frequent  micturition,  sometimes  almost  amounting  to  incon- 
tinence. At  these  times  the  urine  became  very  thick  and 
offensive;  and  at  other  times  there  was  pus  in  small,  but 
distinct,  quantity  in  the  urine.  There  was  marked  tenderness 
on  bimanual  examination,  so  that  renal  calculus  was  suspected. 
Twelve  months  before  her  symptoms  began  she  was  thrown 
from  a  horse  on  to  a  heap  of  stones  and  a  good  deal  shaken. 
Possibly  this   had  some  influence   in  causing   the  condition 


ORIGIN  AND   PROGRESS   OF  RENAL   SURGERY.        2] 

found  at  the  operation.  After  consulting  with  Sir  William 
Roberts  and  Dr.  Cullingworth,  it  was  decided  that  the 
kidney  should  be  explored  and  fixed ;  and  Dr.  Culling- 
worth and  Mr.  Burghard  were  present  at  the  operation. 
Through  a  lumbar  incision  the  upper  end  of  the  kidney  was 
seen  to  be  firmly  bound  down  by  tough  fibrous  adhesions, 
almost  as  hard  as  cartilage.  In  the  contraction  of  these 
adhesions  the  kidney  had  become  slewed  round,  so  that  its 


SIDE 

Fig.  5.— Mode  of  applying  the  sutures  after  division  of  the  stricture.  From  same 
case  as  Fig.  4.  In  the  side  view  the  pucker  caused  by  tightening  the  sutures  is 
somewhat  exaggerated  in  the  figure. 

upper  end  had  been  drawn  lower  than  its  lower  end,  and 
the  front  surface  came  to  look  backwards.  At  least  this  was 
the  explanation  of  the  abnormal  position  which  suggested 
itself  during  the  operation.  The  pelvis  of  the  kidney  was 
distended  to  the  size  of  a  tennis  ball,  and  the  ureter,  Avhich 
joined  the  infundibulum  normally  at  its  lower  point,  was  so 
constricted  as  barely  to  admit  the  smallest  ureteral  catheter 
(see  Fig.  4).  The  kidney  was  incised  along  the  convex 
border  and  thoroughly  explored  for  stone.  None  was  present, 
but  the  calyces  were  found  slightly  sacculated.  The  con- 
stricted orifice  of  the  ureter  was  longitudinally  divided  upon 
the  catheter,  which  was  passed  from  a  small  opening  in  the 


22  HUNTEBIAN  LECTURES. 

mfundibulum  through  the  stricture  to  the  bladder,  and  the 
ends  of  the  incision  were  drawn  together,  by  the  Heinecke- 
Mikulicz  method,  by  means  of  two  fine  silk  sutures,  passed  after 
the  manner  of  Lembert  (see  Figs.  4  and  5).  The  wound  of 
the  renal  parenchyma  was  sutured  with  silk.  Nephropexy 
was  then  performed  by  Vulliet's  plan.  The  wound  healed 
entirely  by  first  intention,  and  there  has  been  no  return  since 
of  the  symptoms  which  led  to  the  operation. 

Resection  of  the  Ureter  is  the  operation  whereby  an  inch 
or  two,  or  a  little  more,  of  the  duct  is  removed,  and  the  ureter 
is  united  to  the  infundibulum,  or  the  divided  ends  of  the 
ureter  to  one  another,  as  the  case  may  be,  so  as  to  restore  the 
continuity  of  the  conduit. 

It  was  first  proposed  by  Marcel  Beaudoin  in  1891,  and  first 
performed  by  Krister  in  May,  1891.  Kttster's  case  is  a  most 
important  one,  not  only  as  being  the  pioneer  case,  but  as  a 
serious  warning  that  we  ought  to  practise  conservatism  in 
dealing  with  the  kidney;  and  an  indication  that  in  hydro- 
nephrosis, nephrectomy  ought  to  give  place  to  nephrotomy, 
or  to  ureterotomy,  in  any  case  in  which  either  of  these 
operations  gives  promise  of  success. 

Ktister  reported  his  case  at  the  Congress  of  Surgeons  held 
in  Berlin  in  1892.*  The  patient  was  a  boy,  aged  thirteen, 
with  only  a  single  kidney,  who  for  two  years  had  passed  all 
his  urine  through  a  fistula,  following  lumbar  nephrotomy,  for 
hydronephrosis.  The  cause  of  the  hydronephrosis  was  a  very 
tight  stricture  of  the  ureter  near  the  renal  pelvis.  The 
strictured  part  of  the  ureter  was  excised,  and  the  cut  end 
of  the  ureter  was  sutured  to  the  renal  pelvis.  .  By  the  end 
of  four  months  from  the  date  of  this  operation  all  the 
urine  was  passed  naturally,  and  the  fistula  was  quite  closed. 

In  the  discussion  on  Krister's  communication  at  the 
Berlin  Congress,  Trendelenburg  and  Alsberg  reported  that 
they  had  each  done  a  similar  operation.  Trendelenburg 
added  that  his  patient  had  died  from  intestinal  obstruc- 
tion, due  to  adhesions  between  the  hydronephrotic  sac  and 
the  colon. 

Cramer  of  Cologne  followed  Krister's  lead  in  a  case  of 
hydronephrosis  in  1893 ;  and  again  in  operating  on  a  case  of 

*  Archiv  fur  Klinisclic  Chirnrgie,  vol.  xliv.,  1892,  p.  850. 


ORIGIN  AND   PROGRESS   OF  RENAL   SURGERY.        23 

pyonephrosis  in  1894  ;  in  both  a  non-urinary  short  fistula  was 
present  when  the  patients  were  last  seen.* 

Enclerlen,  in  a  paper  on  the  "Surgery  of  the  Ureter," t 
relates  a  case  in  the  practice  of  Helferich,  in  which  Krister's 
operation  was  performed  upon  a  young  woman,  twenty-five, 
with  hydronephrosis.  She  died  on  the  ninth  day  with 
symptoms  of  anuria.  At  the  necropsy,  the  kidney  of  the 
opposite  side  was  also  hydronephrotic  from  an  obliterated 
ureter.  Nephrectomy  in  this  case  would  have  been  even 
more  rapidly  fatal.  As  stenosis  seems  to  have  followed  the  plastic 
operation  in  this  instance,  one  is  led  to  ask  why  a  lumbar  renal 
fistula  was  not  established  as  soon  as  the  signs  of  anuria  set  in. 

M.  Bazy  (Acad,  de  Med.,  May  30th,  1897)  in  October,  1896, 
performed  a  precisely  similar  operation  to  Kiister's,  to  which 
he  gave  the  name  of  uretero-pyelo-neostomie. 

His  patient  was  a  man,  aged  forty,  with  a  large  hydro- 
nephrosis, for  which  relief  was  given  by  evacuating  the  pent- 
up  urine  by  laparotomy.  This  gave  M.  Bazy  the  opportunity 
of  ascertaining  that  the  hydronephrotic  kidney  was  of  very  fair 
secreting  capacity.  The  cause  of  the  distension  was  the  abnor- 
mality of  the  connection  of  the  ureter  with  the  renal  pelvis  :  it 
opened  into  the  infundibulum  above  its  equator  instead  of  at  its 
lowest  part.  The  incision  into  the  hydronephrotic  pouch  was 
prolonged  downwards  and  backwards  ;  four  centimetres  of  the 
ureter  were  cut  away :  the  cut  end  of  the  ureter  was  split 
longitudinally  to  the  length  of  a  centimetre  and  a  half,  so 
as  to  enlarge  the  orifice  of  communication,  and  was  then  fixed 
to  the  back  of  the  dilated  infundibulum  at  its  most  dependent 
part.  On  the  seventh  day  after  the  operation  the  urine  was 
passed  from  the  kidney  operated  to  the  bladder.  One  month 
later  the  abdominal  wound  was  completely  healed.  At  the 
end  of  five  months  the  patient  reported  himself  as  being  in 
in  excellent  health. 

Weller  Van  Hook  in  1893  published  a  case  in  which  he 
practised  Krister's  operation,  but  immediately  he  had  com- 
pleted it  he  found  an  obstruction  in  the  ureter  lower  down, 
and  therefore  removed  the  kidney. 

In  1897  I  operated  upon  a  female  patient  aged  fifty-seven- 

*  Centralbl.f.  Qhirurgie,  1894,  No.  47,  p.  1145. 
f  Deutsche  Zeitschr.f.  Chkurgie,  t.  xliii.,  p.  309. 


24 


HUNTEUIAN  LECTURES. 


for  painful  intermittent  hydronephrosis  and  found  the 
ureter  running  obliquely  in  the  wall  of  the  distended 
renal  pelvis.  In  this  case  I  first  laid  the  ureter  and  renal 
pelvis  freely  open  into  one  another  by  a  longitudinal  in- 
cision, and  stitched  the  divided  edges  of  the  ureter  to  those 
of  the  renal  pelvis.  The  result  was  not  satisfactory,  so  I 
excised  three-quarters  of  an  inch  of  the  ureter,    closed  the 


Fig.  6.  — Abnormal  relation  of  ureter  to  inf undibulum  before  operation 
(Author's  case.     Table  VI.,  No.  17.) 

greater  part  of  the  incision  in  the  renal  pelvis,  and  then 
sutured  the  ureter  to  the  lowest  part  of  the  infundibulum  as 
Ktister  had  done  (see  Figs.  6  and  7).  Again  the  result  did 
not  satisfy  me  because  of  the  small  calibre  and  extreme  tenuity 
of  the  ureter ;  so,  to  avoid  a  fistula  and  a  long  convalescence  on 
the  one  hand,  or  stenosis  of  the  ureter  at  the  site  of  operation 
and  a  subsequent  nephrectomy,  on  the  other  hand,  I  removed 
the  kidney  there  and  then.  Had  the  patient  been  younger 
and  more  robust,  I  should,  even  with  so  small  a  ureter,  have 
given  the  plastic  operation  a  chance  of  succeeding.     The  case 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.       25 

however,  testifies  to  the  feasibility  of  both  Fenger's  and 
Bolster's  operations  when  the  ureter  below  the  constriction 
or  valve  is  of  normal  diameter. 

The  nine  operations  for  resection  of  the  ureter  for  hydro- 
nephrosis (or  pyonephrosis)  above  quoted  show  that  the  aim 
in  our  treatment  of  hydronephrosis  ought  to  be  conservative. 


Fig.  7.- 


-Eelation  of  ureter  to  infundibulum  after  resection. 
(Author's  case.     Table  VI.,  No.  17.) 


Before  actually  proceeding  to  resect  the  ureter  lor  stricture 
or  a  valve,  the  surgeon  should  not  fail  to  ascertain  whether 
there  is  a  clear  channel  in  the  ureter  below  the  stricture  or 
valve  to  be  divided ;  otherwise  he  may  find  that  the  operation 
is  useless  when  completed,  as  it  was  in  Van  Hook's  case. 
It  may  happen,  even  if  the  rest  of  the  ureter  is  unob- 
structed, and  the  plastic  operation  has  been  completed, 
that  the  small  calibre,  or  extreme  tenuity  of  the  walls  of  the 
ureter  may  make  the  operator  dissatisfied  with  the  result,  in 
view  of  probable  future  stenosis.     Under  these  circumstances 


Fig.  8. — Kidney  with  enlarged  pelvis  containing  plates  of  lime.  It  shows  an 
abnormal  relation  of  the  renal  pelvis  to  the  ureter,  which  might  have  been 
remedied  by  operation,  and  thus  the  pyonephrosis  prevented.  [Middlesex 
Hospital,  October  30,  1895.     Author's  case.     Table  VI.,  No.  15.) 


Fig.  9. — A  somewhat  similar  abnormality  is  shown  in  this  specimen,  which  could 
have  been  prevented  or  remedied  by  uretero-pyelo -ileostomy.  (Middlesex 
Hospital  Museum.     Author's  case.     Table  VI. ,  Nos.  10  and  11. ) 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        27 


nephrectomy  will  be  required  after  all.    But  the  attempt  ought 
to  be  made,  in  every  instance  where  the  conditions  are  not 


Fig.  10. — Hydronephrosis.     Ureter  com-  Fig.    11. — -Hydronephrosis.       Ureter 

pressed  by  renal  vessel.    {Guy's  Hos-  kinked  on  renal  pelvis  :    described 

pital  Museum,  No.  1G94.)  as  kinked  over  renal  vein.     (Guy's 

Hospital  Museum,  No.  1693.) 
Abnormalities  remediable  by  uretero-pyelo-neostomy. 

actually  unfavourable,  to  preserve  the  kidney  by  means  of  a 
plastic  operation. 

Ureterectomy. — By  resection  of  the  ureter  is  meant  the 
cutting  out  of  a  short  piece  of  the  duct,  not  exceeding'  two 
to  two  and  a  half  inches,  with  the  object  of  restoring  it  to 
its  proper  capacity  as  a  conduit  of  the  urine  to  the  bladder. 
It  is  a  truly  conservative  operation.  More  extensive  excisions 
of  the  ureter,  and  even  the  removal  of  the  whole  length  of  the 
duct,  have  of  late  years  been  occasionally  practised,  and  with 
most  beneficial  results  ;  but,  like  nephrectomy,  such  opera- 
tions are  of  course  not  of  a  conservative  nature. 

Ureterectomy,  partial  or  complete,  has  been  performed  for 
tuberculosis,  suppuration  in  the  dilated  ureter,  hydrops  of  the 


28 


HUNTERIAN  LECTURES. 


ureter,  and  for  the  cure  of  suppurating  lumbar  fistula  due  to 
the  presence  of  a  diseased  ureter,  after  nephrectomy  had  been 
done.  The  operation  may  be  either  primary  or  secondary. 
It  is  primary  when  the  ureter  is  removed  simultaneously  with 
the  kidney ;  secondary  when  the  excision  of  the  ureter  follows 
the  removal  of  the  corresponding  kidney  as  a  distinct  and 
subsequent  operation. 


Fig.  12. — Renal  capsule  and  ureter  (two-thirds  original  size),  the  seat  of  tuberculous 
disease,  removed  thirty-one  days  after  nephrectomy.  (Middlesex  Hospital 
Museum.     Author's  case.     Table  VII.,  Nos.  20  and  21.) 

Secondary  total  ureterectomy  was  first  performed  piece- 
meal by  Regnier  in  1892,  and  by  Gerster  of  New  York  in  1896  ; 
secondary  partial  ureterectomy  by  Poncet  in  1894,  and  by 
myself  in  March,  1896  (Lancet,  Jan.  1st,  1898,  case  ii.,  p.  19). 
(See  Fig.  12.) 

Primary  total  ureterectomy  was  performed  by  Kelly  of 
Baltimore  in  1896,  and  by  McCosh  in  1896,  and  by  myself 
in  September,  1897  (Lancet,  January  1st,  1898,  page  20, 
case  hi.).  In  my  case  there  had  been  a  partial  excision  of 
the  kidney  previously,  but  the  greater  part  of  the  organ  was 
removed  at  the  same  time  as  the  ureter. 


ORIGIN  AND  PRO  GUESS   OF  RENAL  SURGERY. 


29 


Primary  partial  ureterectomy  was  performed  first  by 
Tuffier  in  1891,  then  by  Postnikow  in  1892,  by  Kelly  and 
myself  in  1893  ;  and  I  have  recently  published  a  case  in  which 
the  ureter  was  extensively  calcareous,  upon  which  I  operated 
in  August,  1895  (see  Fig.  13).     (Lancet,  1898,  vol.  i.,  p.  18.) 

Two  different  routes  have  been  followed  in  the  complete 
removal,  namely,  the  transperitoneal  and  the  extraperitoneal ; 


Fig.  13. — Kidney  and  portion  of  ureter  (half  original  size)  removed  for  tuberculous 
disease  of  the  kidney  and  ureter.  (Middlesex  Hospital  Museum.  Author's 
case.     Table  VII. ,  No.  19.) 

but  the  latter,  when  the  incision  indicated  in  the  accompany- 
ing diagram  (Fig.  24,  p.  117)  is  adopted,  gives  so  complete  and 
satisfactory  a  field  for  the  necessary  manipulations,  and  has 
other  anatomical  and  surgical  advantages,  that  it  is  not  prob- 
able the  transperitoneal  method  will  find  any  followers. 

Several  different  routes  have  been  taken  or  suggested  for 
partial  ureterectomy  affecting  the   lower   part   of  the   duct. 


30 


HUNTEBIAN  LECTURES. 


In  the  male  the  inguinal  extraperitoneal  route,  i.e.  through 
an  incision  the  same  as  the  lower  part  of  the  incision  for 
complete  extraperitoneal  ureterectomy,  is  the  best;  but  in 
the  female  the  para-sacral  as  advocated  by  Cabot  and  Fenger 
{Trans.  Amer.  Surgical  Assoc,  1894,  p.  133),  or  a  combination 
of  the  inguinal  and  vaginal  methods  as  practised  by  Kelly, 
have  advantages  over  the  others  (see  Figs.  14  and  15). 


ROUND    LIG 


UT.  ARTERY 


Fig.  14. — Opening  the  vaginal  vault  to  bring  the  extremity  of  the  right  ureter  through 
into  the  vagina.  One  hand  is  represented  within  the  retroperitoneal  abdominal 
wound,  and  two  fingers  of  the  other  hand  are  within  the  vagina. 

H.  A.  Kelly,  M.D.,  The  Johns  Hopkins  Hospital  Bulletin,  Nos.  59,  60,  Feb.  and 
March,  1896. 


WOUNDS   OF   THE   URETER. 

Another  way  in  which  great  advance  has  been  made 
in  renal  surgery,  in  the  conservative  direction,  is  in  the 
management  of  wounds  of  the  ureter  inflicted  accidentally 
during  the  course  of  such  operations  as  ovariotomy,  abdominal 
and  vaginal  hysterectomy,  and  the  removal  of  suppurating 
fallopian  tubes  and  ovaries.  The  ureter  has  also  been 
wounded  in  at  least  one  instance  during  the  course  of  an 
operation  on  the  pelvis  by  the  method  known  as  Kraske's. 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        31 

Spencer  Wells  (Med.  Chir.  Trans.,  1881),  in  his  paper  on 
the  first  successful  removal  of  a  gravid  cancerous  uterus, 
stated  that  out  of  ninety-four  published  abdominal  hyster- 
ectomies one  ureter  had  been  divided  in  six,  and  both"  ureters 


Fig.  15. — Removal  of  the  lower  end  of  the  ureter  through  the  vagina.     The  ureter 

is  seen  after  it  has  been  pulled  through  the  vaginal  vault. 
H.  A.  Kelly,  M.D.,  Bulletin  of  the  J ohns  Hopkins  Hospital,  vol.  vii.,  Nos.  59  and  60. 

in  two  other  cases.  It  has  since  been  computed  that  in  every 
hundred*  hysterectomies,  vaginal  and  abdominal,  one  or  both 
ureters  are  tied,  or  cut  across  in  at  least  three. 

From  time  to  time  unpublished  cases  are   heard   of  in 

*Dr.  Fred   Byron    Robinson;     Discussion    on    Fenger's    paper    [Chicago 
Medical  Reformer ;  March,  1893,  p.  200). 


32  HUNTERIAN  LLO TUBUS. 

which,   the  ureter  has  been   divided  partly   or   entirely ;    or 
portions  have  been  unintentionally  resected. 

For  these  injuries  nephrectomy  had  hitherto  been  per- 
formed, and  in  many  instances  of  the  kind  healthy  kidneys 
have  been  removed. 

This  is  a  discomforting  reflection;  and,  not  unnaturally, 
as  soon  as  accidental  surgical  wounds  became  of  pretty  fre- 
quent occurrence  there  were  surgeons  who  set  themselves 
to  devise  some  alternative  for  nephrectomy. 

Numerous  experiments  on  animals  were  made  by  Tuffier, 
Boari  and  Pozzi  in  France,  Gusserow  and  Pawlik,  Alfonso 
Poggi  of  Bologna,  Van  Hook,  Byron  Robinson,  Bovee  and 
others  in  America,  and  a  great  variety  of  methods  have  been 
devised  for  remedying  the  injury  without  sacrificing  the  kidney. 

They  may  be  grouped  into  two  distinct  classes,  viz.  : 
(1)  Those  designed  to  restore  the  continuity  of  the  ureter ; 
and,  failing  this,  (2)  those  for  anastomosing  the  cut  end  of 
the  ureter  with  the  external  surface,  with  the  intestine,  or 
with  the  bladder. 

If  the  ureter  should  be  wounded  during  an  abdominal 
or  vaginal  operation,  and  the  injury  is  detected  by  the 
surgeon  at  the  time,  one  or  the  other  of  these  operations 
ought  to  be,  if  possible,  immediately  practised.  Such  a  com- 
plication can  only  be  suitably  grappled  with  by  one  familiar 
with  the  varieties  and  possibilities  of  surgery  which  recent 
experiments  and  scattered  cases  have  brought  to  light. 

It  is  very  desirable,  therefore,  that  surgeons  and  gynae- 
cologists who  are  exposed  to  the  risks  of  injuring  the  ureter 
should  have  a  fair  working  knowledge  of  the  remedies,  short 
of  sacrificing  the  kidney,  which  are  available. 

Uretero-ureteral  Anastomosis. — Schopf,*  in  1886,  was 
the  first  who  practised  uretero-ureteral  anastomosis  in  the 
human  subject.  He  adopted  the  end-to-end  method.  After 
having  accidentally  divided  the  ureter  near  the  pelvic  brim, 
when  removing  an  ovarian  cyst,  he  used  eight  fine  silk  sutures, 
passing  them  through  the  cellular  and  muscular  tissues  only, 
to  unite  the  ureter  end  to  end.  The  patient  made  an  un- 
eventful recovery  from  the  operation,  but  died  seven  weeks 
later  of  tuberculosis.     The  inference  to  be  drawn  from  the 

*  F.  Schopf,  Centralblatt  fur  Gijnakologie,  No.  30,  1887. 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        33 

account  of  the  autopsy  is,  that  there  was  cicatricial  stenosis 
about  the  seat  of  operation. 

E.  W.  Cushing  of  Boston  recorded  the  second  case  of  the 
end-to-end  method,  and  speaks  of  his  operation  as  being 
original,  by  saying  that  it  forms  "  a  rare,  if  not  unique, 
incident  in  the  surgery  of  the  ureter."*  Pawlik,  Tuffier, 
HochenesfS',  and  H.  Fritsch  are  the  other  surgeons  who  have 
employed  the  end-to-end  method. 

In  1887  Alfonso  Poggif  (of  Bologna)  suggested  the  plan 
(based  on  experiments  on  dogs),  of  invaginating  the  upper  into 
the  lower  end  of  the  divided  ureter.  This  is  the  end-in-end 
method. 

In  1893  Van  Hook$  of  Chicago  published  a  description 
of  his  experiments  on  dogs,  for  the  lateral  implantation  of 
the  upper  portion  of  the  ureter  into  an  opening  in  the 
side  of  the  lower  portion.  Both  Poggi  and  Van  Hook 
were  so  impressed  by  their  respective  experimental  re- 
sults that  they  considered  a  trial  of  their  operations  upon 
man  justified. 

Weller  Van  Hook's  operation,  by  lateral  implantation,  is 
performed  as  follows : — 

1.  The  lower  segment  is  closed  by  a  ligature,  one-eighth  to 
a  quarter  of  an  inch  from  its  free  end.  Then,  with  fine, 
sharp-pointed  scissors,  a  longitudinal  incision  is  made  in  the 
wall  of  this  segment  of  the  duct,  a  quarter  of  an  inch  below 
the  ligature.  This  incision  is  twice  as  long  as  the  diameter  of 
the  ureter. 

2.  A  longitudinal  incision,  a  quarter  of  an  inch  long,  is 
made  in  the  open  end  of  the  upper  segment.  This  incision 
insures  the  patency  of  the  duct. 

3.  Two  small  cambric  sewing  needles,  armed  with  one 
thread  of  sterilised  catgut,  are  passed  through  the  wall  of 
the  upper  part  of  the  ureter,  opposite  the  slit  at  the  open  end, 
and  one-eighth  of  an  inch  from  the  extremity,  from  within 
outwards ;  the  needles  transfix  the  wall  one-sixteenth  of  an 
inch  apart,  and  equidistant  from  the  cut  end. 

4.  The  needles  are  now  carried  through  the  slit  in  the  side 

*  Annals  of  Gynecology  and  Pediatry,  vol.  vii.,  February,  1893. 

t  Riforma  Medica,  1887-8,  N.S.  via.,  39. 

\  Journal  of  American  Medical  Association,  No.  21,  July — December,  1893. 


34 


HUNTERIAN  LECTURES. 


of  the  lower  segment  of  the  ureter,  and  made  to  transfix  the 
wall,  side  by  side,  half  an  inch  lower  down  the  tube. 

5.  By  drawing  in  the  two  ends  of  the  suture,  the  upper 
portion  of  the  ureter  is  drawn  into  the  lower,  and  the  ends  of 
the  suture  are  firmly  tied  together.  As  the  catgut  becomes 
absorbed  in  a  few  days,  calculi  do  not  form  upon  this  suture 
and  obstruct  the  passage  of  urine. 

6.  The  ureter  at  the  seat  of  union  is  now  enveloped  care- 
fully with   peritoneum.     This   may  be   done   by   lifting   the 


Fig.  16. — Van  Hook's  method  of  lateral  implantation. 
Journal  of  American  Medical  Association,  vol.  xxi.,  July — December,  1893. 

ureter  gently  into  the  cavity  of  the  peritoneum,  drawing  the 
serous  membrane  carefully  behind  the  ureter,  and,  after 
pulling  the  peritoneum  around  the  ureter,  stitching  it  in 
position,  to  permanently  enclose  and  protect  the  duct.  Or, 
the  ureter  may  be  surrounded  in  a  completely  detached  fold 
of  omentum,  Avhich  is  loosely  attached  by  a  stitch  to  the 
connective  tissue  about  the  duct. 

The  omental  method  is  less  secure  than  the  other,  since 
the  omentum  is  deprived  of  its  blood  supply. 


ERRATUM. 

Page  35.— In  inscriptions  to  Figs.  17  and  IS,  for  "in- 
flammation" read  "implantation." 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.       35 


Howard    Kelly   of  Baltimore,  B.  Emmet   of  New  York 
and  Doherty  of  Georgia  have  successfully  applied  Van  Hook's 
operation  to  the  ureters  of  women. 

When  the  upper  portion  of  the  divided  ureter  is  very  much 


Fig.  17. — Emmet's  method  of  lateral  inflammation. 
Bache  Emmet,M.D.,  New  York,  American  Journal  of  Obstetrics ,  April,  1895,  vol.  xxxi. 


Fig.  18. — Emmet's  method  of  lateral  inflammation. 
Bache  Emmet,  American  Journal  of  Obstetrics,  April,  1895. 

distended,  and  has  to  be  puckered  to  get  it  into  the  lower 
portion,  which  may  be  only  half  its  size,  or  even  less,  three 


36  HUNTERIAN  LECTURES. 

sutures,  instead  of  one,  might  be  advantageously  employed 
as  was  done  by  Emmet.*  This  may  be  the  condition  of 
things  if  the  ureter  happens  to  be  cut  just  where  the  pressure 
of  the  tumour  or  adhesions  had  been  exercised.  Emmet's 
abdominal  operation  was  the  removal  of  an  cedematous 
fibroid,  attached  over  the  fifth  lumbar  vertebra,  and  which 
had  been  at  one  time  attached  to  the  uterus. 

In  Kelly's  case,  operated  upon  in  May,  1892,t  as  the 
result  of  pressure  from  an  uterine  myoma,  the  ureter  was 
enlarged  to  four  times  its  normal  circumference,  forming  a 
well-marked  hydro-ureter.  The  operation,  therefore,  was 
much  easier  than  it  would  have  been  on  a  normal  ureter. 
Kelly  used  two  sutures,  instead  of  one  as  Van  Hook  did ;  and 
passed  them  with  a  single  needle,  commencing  the  passage  of 
the  sutures  below  the  slit  in  the  lateral  Avails  of  the  lower 
segment  of  the  ureter.  Ten  fine  silk  rectangular  sutures, 
catching  only  the  outer  coat,  then  united  the  edges  of  the 
slit  to  the  intussuscepted  portion. 

Van  Hook  points  out  an  important  fact  in  connection 
with  these  ureteral  operations,  namely,  "  the  lumen  of  the 
tube  can  be  enormously  increased  by  stretching,  without 
prejudice  to  the  integrity  of  its  walls."  Emmet  verified  this 
in  his  operation,  where  it  was  of  great  moment  to  stretch  the 
lower  segment,  owing  to  the  great  dilatation  of  the  upper. 

Finally  Bovee,  in  1895,  adopted  a  plan  which  consists  in 
suturing  the  cut  ends  together  obliquely.  He  published  an 
account  of  it  in  January,  18974  He  performed  his  operation 
on  a  woman  set.  thirty-six,  whose  right  ureter  he  unintentionally 
included  in  a  ligature  and  then  divided,  when  excising  the 
right  ovary  and  tube  for  an  abscess.  He  converted  the  trans- 
verse division  of  the  ureter  into  an  oblique  one,  with  some  loss 
of  length  of  the  duct.  This  seemed  necessary,  as  the  lower  end 
had  been  grasped  too  tightly  by  strong  forceps,  and  the  upper 
end  by  the  ligature ;  thus  both  ends  were  damaged. 

The  cut  ends  were  then  dilated  for  an  inch,  and  approxi- 
mated with  No.  1  silk,  such  as  is  used  in  intestinal  operations ; 
then  the  ends  were  joined  by  rectangular  sutures,  with  two 

*  Bache  Emmet,  The  American  Journal  of  Obstetrics,  April,  1895. 
f  Eeported  in  Bull,  of  Johns  Hopkins  Hospital,  for  October,  1893. 
\  Wesley  Bovee  :  Annals  of  Surgery,  Jan.,  1897,  also  Sept.,  1S97,  p.  318. 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        37 

interrupted  sutures  intervening  between  each  two  rectangular 
sutures.  Over  these  sutures  four  or  five  other  sutures  were 
inserted,  which  reached  a  little  further  up  and  down  the  duct 
than  the  rest.  The  recovery,  immediate  and  remote,  was 
very  satisfactory.  No  sutures  penetrated  the  mucous  mem- 
brane of  the  ureter.  The  peritoneum  was  carefully  sutured 
over  the  injured  portion  of  the  duct. 

Four  methods  have  been  employed,  as  we  have  now  seen, 
for  uniting  the  cut  ends  of  the  ureter. 

1.  The  lateral  implantation   devised   by  Van   Hook  has 


Fig.  19. — Uretero-ureteral  anastomosis  by  the  oblique  method  of  Bovee. 
J.  "Wesley  Bovee,  Annals  of  Surgery,  Part  49. 


been  successfully  performed  on  three  women  by  different 
operators  in  each  case.  It  has  led  to  no  contraction  or 
stenosis  in  experimenting  on  dogs. 

2.  The  transverse  end-to-end  union  has  been  practised 
seven  times  on  the  human  ureter.  Four  of  these  cases  have 
been  described  as  cured.  Three  died  from  causes  quite 
unconnected  with  the  ureteral  operation,  one  being  from 
tuberculosis  seven  weeks  afterwards,  and  the  other  two 
directly  or  indirectly  from  the  operation  during  which  the 
accident  to  the  ureter  happened. 


38  HUNTEBIAN  LECTURES. 

3.  The  oblique  end-to- end  anastomosis  devised  by  Bovee 
and  performed  by  him  once  and  with  success. 

4.  The  end-in-end  invagination  of  the  upper  into  the 
lower  portion  of  the  ureter,  or  the  method  of  Poggi,  has  been 
employed  at  least  once  successfully  on  a  woman,  and  Poggi's 
experiments  on  dogs  were  eminently  successful. 

Budinger's  and  Turner's  experiments  on  dogs  of  the  end- 
to-end  and  end-in-end  methods  respectively  gave  deplorable 
results. 

Out  of  the  twelve  cases  of  the  application  of  these  methods 
to  ureters  injured  during  surgical  operations,  in  eleven  the 
section  of  the  duct  was  complete  and  in  one  incomplete 
(Pawlik's  case). 

To  this  case  of  incomplete  section  of  the  ureter  I  may  add 
one  of  my  own,  in  which  the  dilated  ureter  was  three  parts 
divided.  In  both  of  them  the  mode  of  treatment  was 
practically  the  same — viz.  closure  of  the  wound  by  very 
fine  silk  sutures  passed  in  the  fashion  of  Lembert,  and 
covering  the  injured  ureter  with  the  peritoneum. 

Pawlik's  case  died  of  shock  fourteen  hours  after  the 
operation.  My  patient  died  fifty-one  hours  after  the  opera- 
tion, but  the  union  was  found  secure  and  able  to  bear  the 
pressure  of  a  stream  of  water  forcibly  injected  along  the 
ureter  from  the  infundibulum  to  the  bladder.  Had  this 
woman  lived  there  is  good  reason  for  thinking  that  stenosis 
would  not  have  occurred,  because  of  the  dilated  condition 
of  the  ureter. 

My  patient  was  a  woman  thirty-six  years  of  age,  who  for 
eighteen  months  had  been  suffering  from  continual  pain  and 
frequent  attacks  of  vomiting  caused  by  a  large  uterine  myoma 
which  was  rapidly  growing.  Complete  abdominal  hysterec- 
tomy was  performed  on  July  21st,  1897.  The  operation 
went  quite  smoothly  except  for  the  accident  to  the  ureter, 
which  was  immediately  recognised,  and  the  cut  ends  of  the 
ureter  were  united  after  the  hysterectom}^  was  completed, 
During  the  first  twenty-four  hours  after  the  operation 
only  seven  and  a  half  ounces  of  urine  (free  of  blood)  were 
secreted.  Vomiting  was  excessive  and  continuous.  During  the 
second  twenty-four  hours  twenty-seven  ounces  of  urine  were 
passed,  and  contained  no  trace  of  blood.     At  the  post-mortem 


ORIGIN  AND  PROGRESS   OF  RENAL   SURGERY.        39 

examination  both  kidneys  were  excessively  hydronephrotic ; 
the  right  could  scarcely  be  said  to  exist,  its  parenchyma 
was  so  atrophied.  The  calyces  of  the  left  kidney  were 
greatly  dilated,  and  the  cortical  substance  was  very  thin.  Both 
ureters  and  the  renal  infundibula  were  considerably  dilated. 
The  left  ureter,  just  beyond  its  entrance  into  the  broad 
ligament,  had  been  wounded  and  closed  by  sutures,  and 
the  peritoneum  was  stitched  over  the  united  ends.  The  tube 
was  quite  watertight,  as  tested  by  a  strong  current  of  water. 
There  was  no  peritonitis,  and  the  wound  was  healing. 

It  would  be  impossible  now  to  enter  into  a  minute 
comparison  of  these  four  methods.  As  far  as  results  go, 
all  seem  to  be  upon  the  same  footing,  for  they  have  all  been 
tested  in  the  human  living  subject,  and  from  reports  published 
some  months  or  years  after  the  operations  no  subsequent 
trouble  seems  to  have  occurred  to  the  kidneys. 

Personally,  I  may  say  that  if  the  ureter  was  completely 
divided,  and  was  also  much  dilated,  I  should  adopt  Bovee's 
oblique  end-to-end  method.  If  the  ureter  was  completely 
divided  but  not  dilated,  I  should  prefer  Van  Hook's.  Bovee's 
might  be  employed  where  there  is  a  rather  greater  loss  of 
substance  than  could  be  overcome  by  Van  Hook's  method, 
but  the  latter  would  be  much  more  rapidly  executed. 

For  transverse  wounds  which  do  not  completely  divide 
the  ureter,  but  involve  one-third  or  more  of  its  circumference, 
Van  Hook  has  proposed  the  following  operation  :  "  Make  two 
longitudinal  incisions  in  the  ureter  with  a  pair  of  small  scissors, 
besrinnine'  at  the  middle  of  the  wound  to  be  closed.     These 

o  o 

incisions  should  be  equal  in  combined  length  to  twice  the 
transverse  diameter  of  the  tube.  Round  off  the  sharp  angles 
of  tissue  with  the  scissors  and  suture  longitudinally  "  (i.e.  in 
the  direction  of  the  long  axis  of  the  tube)  "  with  the  object  of 
producing  a  very  wide  instead  of  a  very  contracted  lumen." 
By  this  method  cicatricial  contraction  cannot  obstruct  the 
flow  of  urine.  When  the  wound  involves  the  peritoneal 
aspect  of  the  duct  (as  it  necessarily  does  in  accidents  during 
abdominal  operations),' he  advises  that  the  union  should  be 
protected  by  surrounding  it  with  a  fold  of  peritoneum. 

Fenger  thinks  that  even  for  incomplete  transverse  wounds, 
when  intra-peritoneal,   that   it   will   be   safer   to   divide   the 


40  SUNTERIAN  LECTURES. 

ureter  completely,  and  then  to  resort  to  Van  Hook's 
method  of  lateral  implantation,  which,  he  says,  is  a 
tried  and  successful  operation.  Emmet  is  of  the  same 
opinion. 

A  mere  puncture,  or  a  small  wound  which  merely  gapes 
slightly,  may  be  securely  closed  by  one  or  more  Lembert 
sutures  and  a  covering  of  peritoneum.  I  am  of  opinion  that 
in  many  cases,  where  one-third  or  more  of  the  circumference 
is  involved,  that  the  same  method,  viz.  Lembert  sutures  and  a 
covering  of  peritoneum,  will  suffice.  If  it  is  remembered  that  in 
many  of  the  cases  in  which  the  ureter  is  injured  during  an 
intra-peritoneal  operation  the  tube  is  more  or  less  dilated,  it 
is  not  necessary  to  consider  with  Van  Hook  that  every  in- 
complete transverse  section  of  the  ureter  when  closed,  either 
by  cicatrisation  or  primary  union  after  direct  suture,  will  have 
a  tendency  to  result  in  stenosis.  The  case  I  have  alluded  to 
above  justifies  me  in  this  opinion. 

If  the  ureter  was  divided  through  half  or  more  of  its 
circumference  and  dilated,  I  should  do  again  what  I  did 
in  this  case.  If  the  ureter  was  not  dilated,  I  should 
employ  one  of  the  methods  of  Van  Hook,  being  guided  by 
circumstances  as  to  which. 

The  classes  of  cases  in  which  uretero-ureteral  anastomosis 
is  applicable  are  the  following : — 

To  restore  the  continuity  of  the  duct  (1)  after  accidental 
section  during  abdominal  operations. 

(2)  After  unintentional  resection  of  a  short  length  of  the 
duct  during  abdominal  operations.  Two  or  even  three  inches 
may  be  removed,  and  the  ends  afterwards  brought  together 
without  undue  tension  on  the  union. 

(3)  After  resection  of  a  portion  of  the  ureter  for  strictures, 
ulceration,  sloughing  around  a  calculus,  or  any  other  con- 
dition which,  if  not  removed,  would  terminate  in  stenosis. 

(4)  After  rupture  and  other  injuries  from  external  violence 
— as  soon  as  the  case  is  diagnosed  when  intra-peritoneal ;  and 
before  suppuration  or  sloughing  occurs  when  retro-peritoneal. 

Ureteral  Grafting". — An  immense  amount  of  labour  and 
ingenuity  has  been  given  to  devising  methods  (1)  for  the  cure 
of  ureteral  fistula,  (2)  for  the  prevention  of  ureteral  fistula, 
and  of   nephrectomy,  in  cases  in  which  there   has    been  a 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.        41 

loss   of   substance    too   great   to    permit   of   uretero-ureteral 
anastomosis. 

Very  numerous  have  been  the  experiments  to  test  the 
feasibility  of  grafting  the  cut  end  of  the  ureter  (1)  into 
the  bladder,  (2)  into  the  rectum,  (3)  into  other  parts  of  the 
small  and  large  intestines,  and  (4)  on  to  the  skin  in  the  loin. 

Various  other  ingenious  plans  have  been  proposed  as 
substitutes  for  nephrectomy,  whereby  the  urine  is  conducted 
to  the  bladder  even  after  parts  of  the  ureter,  too  great 
to  permit  of  uretero-ureteral  anastomosis,  or  of  bladder- 
grafting,  have  been  cut  away,  or  otherwise  destroyed.  But 
the  results  of  actual  operations  show  that  grafting  into  the 
bladder — uretero-cysto-neostomie,  as  Bazy  has  named  it — 
should  be  always  the  operation  of  choice  Avhen  it  can  possibly 
be  done. 

All  this  industry  is  the  result  of  the  comparative  fre- 
quency of  uretero-vaginal  and  uretero-uterine  fistulas,  especi- 
ally since  the  vulgarisation  of  vaginal  hysterectomy.  Thus  a 
great  many  ingenious  operations,  some  of  great  difficulty 
and  requiring  attention  to  very  minute  operative  details, 
have  been  practised,  or  proposed,  with  the  object  of  avoiding 
nephrectomy. 

How  needful  this  is  must  be  only  too  well  known  to 
surgeons  who  have  experienced  the  difficulties  of  identi- 
fying the  kidney  which  is  in  connection  with  the  fistula. 
The  following  is  a  case  in  point :  A  woman  who  had  under- 
gone vaginal  hysterectomy  by  a  distinguished  gynaecologist 
recovered  with  an  uretero-vaginal  fistula.  The  patient  was 
handed  over  to  a  distinguished  general  surgeon  to  be  cured  of 
this  fistula.  Efforts  were  made  in  a  most  careful  manner  to 
ascertain  which  ureter  it  was  which  had  been  wounded  and 
become  entangled  in  the  vaginal  cicatrix.  These  failing 
to  afford  definite  information,  the  ureter  of  the  suspected 
kidney  was  exposed  through  a  lumbar  incision  and  was 
temporarily  ligatured.  During  this  experiment,  which  was 
of  course,  made  under  chloroform,  no  urine  escaped  by 
the  vagina,  but  a  certain  amount  was  withdrawn  by 
catheter  from  the  bladder  at  the  expiration  of  a  given  time. 
The  inference  was  that  the  ureter  temporarily  ligatured  was 
the  one  involved  in  the  vaginal  fistula ;  so  the  corresponding 


42  EUNTERIAN  LECTURES. 

kidney  was  there  and  then  excised.  Imagine  the  surgeon's 
chagrin,  and  the  patient's  distress,  the  next  day  when  it  was 
discovered  that,  though  she  had  lost  a  healthy  kidney,  the 
operation  had  not  cured  her  of  the  fistula;  for  the  wrong 
organ  had  been  removed. 

It  is  impossible  for  me  here  to  describe  the  work  done, 
or  even  to  name  the  many  workers  in  this  field  of  experi- 
mental and  clinical  surgery.  I  can  only  mention  briefly 
the  most  satisfactory  plastic  operations  upon  the  ureter  by 
vesical  grafting.     They  may  be  classified  as  follows  : — 

1.  Invaginating  the  fistulous  aperture  itself  into  the  bladder 
after  first  incising  the  vesico-vaginal  septum. 

2.  Grafting  the  ureter  to  the  bladder  through  the 
vagina. 

3.  Grafting  the  ureter  into  the  bladder  by  an  extra- 
peritoneal route  through  an  incision  in  the  abdominal  wall. 

4.  Grafting  the  ureter  into  the  bladder  by  a  trans- 
peritoneal or  intra-peritoneal  operation. 

Since  Simon  first  practised  nephrectomy  as  the  remedy 
for  ureteral  fistula,  this  operation  has  been  frequently 
performed  for  this  cause  up  to  the  present  time.  Tuffier, 
in  a  recently  published  communication,  refers  to  twenty- 
four  cases  which  he  had  collected.  But  with  our  present 
knowledge  of  the  surgery  of  the  ureter,  nephrectomy  for 
fistula  has  become  in  most  instances,  I  do  not  say  in  all,  an 
unjustifiable  procedure.  It  ought  to  be  reserved  for  quite 
exceptional  cases — as,  for  instance,  where  the  state  of  the 
kidney  itself  is  prejudicial  to  health  ;  or  when  the  surgeon, 
having  tried  and  failed,  has  given  up  the  attempt  to  cure 
a  troublesome  and  loathsome  fistula  by  plastic  operation. 

Nephrectomy  as  a  primary  operation  for  surgical  injuries 
of  the  ureter  is  quite  unjustifiable;  and  as  a  secondary 
operation  for  these  injuries  it  comes  under  the  criticism  just 
made  upon  it  for  the  treatment  of  fistula. 

As  a  remedy  for  movable  kidney,  nephrectomy  has  come 
and  gone,  never,  it  is  hoped,  to  return. 

In  cases  of  limited  suppuration,  of  circumscribed  tuber- 
culous disease,  of  innocent  growths,  and  in  certain  injuries 
of  the  kidney,  partial  excisions  are  now  being  performed  in 
place  of  nephrectomy. 


ORIGIN  AND  PROGRESS   OF  RENAL  SURGERY.       43 

In  many  instances  of  calculous  pyonephrosis  irrigation  of 
the  renal  calyces  and  infundibulum,  followed  by  suture  of 
the  kidney,  has  taken   the   place  of  nephrectomy. 

In  hydronephrosis  a  few  laudable  attempts  have  been 
made,  and  in  a  good  proportion  of  them  with  success,  to 
remove  the  cause  of  the  obstruction  by  means  of  a  plastic 
operation,  and  thus  to  spare  the  kidney. 

In  fact,  the  tendency  of  the  surgery  of  to-day  is  to  save  as 
much  of  the  kidney  tissue  as  possible,  consistently  with  the 
safety  and  well-being  of  the  patient. 

In  this  imperfect  survey  of  the  origin  and  progress 
of  renal  surgery,  I  hope  I  have  succeeded  in  showing  that 
whilst  its  origin  was  nephrectomy,  its  progress,  especially 
during  the  last  ten  years,  has  been  in  the  direction  of  ren- 
dering nephrectomy  more  and  more  an  operation  to  be 
avoided. 


LECTURE    II. 

RENAL  CALCULUS  :  THE  DIFFICULTIES  AND  ERRORS 
IN  DIAGNOSIS  IN  THEIR  RELATION  TO  EX- 
PLORATION OF  THE  KIDNEY  :  UNSUSPECTED, 
QUIESCENT,  AND  MIGRATORY  CALCULI. 

Mr.  President  and  Gentlemen, — To-day  I  wish  to  draw 
attention  to  renal  calculous  disorders.  If  I  put  them  in 
the  very  forefront  of  surgical  affections  of  the  kidney,  I  do 
so  for  the  following  reasons  : — 

1.  They  are  the  most  frequent  and  most  painful  of  the 
surgical  diseases  of  the  kidney.  Probably  no  disease,  except 
acute  tetanus,  is  capable  of  causing  worse  suffering. 

2.  Few  operations  in  surgery  are  so  successful  as  nephro- 
lithotomy, by  which  a  calculus  is  removed  from  a  kidney 
which  has  not  become  disorganised  by  the  calculus  or  other- 
wise. No  great  operation  is  followed  by  a  smaller  mortality. 
Nephrolithotomy  gives  absolute  cure,  saving  the  kidney 
from  progressive  destruction,  and  the  patient  from  what  at 
any  moment  may  prove  to  be  an  imminent  danger  to  life. 

3.  No  disease  gives  rise  to  such  a  variety  of  morbid 
changes  in  the  kidney  as  calculus ;  and  none  is  more  certainly 
fatal  when  allowed  to  progress  without  surgical  interference. 

4.  Renal  calculus,  whilst  slowly  or  silently  destroying  the 
kidney,  often  physically  disables  its  victim  by  its  unrelenting 
irritation,  and  its  unyielding  resistance  to  every  form  of 
medical  and  dietetic  treatment. 

5.  Renal  surgery  will  grow  in  confidence  and  in  favour 
with  the  profession  and  the  public  as  nephrolithotomy 
anticipates  and  displaces  nephrotomy  and  nephrectomy. 

I  attempted  to  show,  in  the  latter  part  of  the  first  lecture, 
that  nephrectomy  is  being  rapidly  restricted  in  its  application 
as  advances  are  made  in  ureteral  operations.  It  may  also  be 
safely  asserted  that  nephrotomy,  at  present  the  most  frequent 
operation  resorted  to  for  calculous  affections,  will  be  required 
but  rarely  if  nephrolithotomy  is  earlier  and  oftener  performed. 


RENAL   CALCULUS. 


45 


Calculous  pyonephrosis  is  the  result  of  long-standing  irri- 
tation and  progressive  destruction  of  the  kidney,  and  there 
is  no  reason  why  it  should  ever  occur  if  physicians  would 
recommend,  and  surgeons  would  practise,  early  operations  for 
stone  in  the  kidney.  That  this  is  a  consummation  much  to 
be  desired  is  seen  by  comparing  the  mortality  of  nephro- 
lithotomy with  that  of  nephrotomy  and  nephrectomy  for 
calculous  conditions,  as  shown  by  the  Tables  at  the  end  of  this 
volume :  the  following  figures  are  derived  from  them  : — 


Cases. 

Recoveries. 

Deaths. 

Percentage 

Mortality. 

Nephrolithotomy      .     . 
Nephrotomy  .... 
Nephrectomy       .     .     . 

34 
43 

17 

33 
33 
12 

5 

2-9 
23-25 

29-4 

Case  21  in  the  tahle  of  Nephrotomies  and  Case  16  in  the  table  of  Neph- 
rectomies are  excluded  for  obvious  reasons. 


6.  Another  reason  why  calculous  disorders  take  so  pro- 
minent a  lead  amongst  the  surgical  affections  of  the  kidney 
is  because  of  the  difficulties  and  errors  attending  their 
diagnosis.  These  difficulties  arise  from  four  chief  [causes  : — 
1.  Several  other  renal  and  ureteral  affections  give  rise  to  the 
same  symptoms  as  stone.  2.  Several  diseased  conditions  of 
other  organs  cause  symptoms  which  simulate  those  of  renal 
calculus.  3.  Symptoms  caused  by  renal  calculus  may  be  trans- 
ferred to  other  organs  ;  or  may  be  of  a  psychical  order,  with  or 
without  high  temperature,  and  may  not  be  referred  at  all  to 
the  kidney  itself.  4.  Calculi  may  be  for  an  indefinite  time 
masked,  giving  rise  to  no  symptoms  whatever,  yet  causing 
the  while  progressive  destruction  of  the  kidney. 

When  calculi  have  been  previously  passed,  when  well- 
marked  attacks  of  renal  colic  occur,  when  crystals  of  uric 
acid  or  calcium  oxalate  are  frequently  found  in  the  urine,  and 
when  the  urine  is  intermittently  mixed  with  a  good  deal  of 
blood,  or  persistently  contains  a  microscopicJ,quantity,  there 
are  the  strongest  a  'priori  grounds  for  thinking  that  a  stone 
is  present.  This  evidence  is  strengthened  if  attacks  of  colic 
and  hematuria  are  readily  induced  by  exercise^  or  jolting, 
and  readily  subside  with  rest ;  and  if  a  sharp  pain  or  distinct 


46  HUNTERIAN  LECTURES. 

tenderness  is  always  caused  by  bimanual  examination  of  the 
renal  region.  In  many  cases,  however,  mistakes  in  diagnosis 
are  bound  to  arise.  Morbid  conditions  other  than  stone  Avill 
be  found,  from  time  to  time,  in  cases  in  which  the  character  of 
the  pain  and  the  state  of  the  urine  point  to  calculus  as  the  pro- 
bable cause.  These  mistakes  are  apt  to  excite  a  prejudice  against 
renal  exploration ;  but  the  results  obtained  by  those  who  have 
had  large  practice  in  renal  surgery  ought  to  correct  this.  The 
experience  gained  by  operations  has  taught  us  much  as  to 
what  the  conditions  are  which  cause  symptoms  typical  of 
stone  when  no  stone  exists. 

In  1892  I  published  some  lectures  on  the  conditions 
simulating  renal  calculus  as  verified  by  surgical  exploration 
in  twenty-eight  cases.  To  these  I  now  add  sixteen  cases, 
making  forty-four  in  all.  In  a  few  instances  a  calculus 
was  possibly  in  the  ureter  at  the  time  of  the  exploration, 
because  one  was  passed  some  little  time  subsequently. 
But  in  the  greater  number  of  the  forty-four  cases  some 
other  morbid  state  of  the  kidney  was  found  and  remedied. 
It  is  certain  that  the  diagnosis  of  calculus,  though  incorrect, 
was  advantageous  to  these  patients,  for  the  very  reason  that 
it  led  to  the  exploration,  and  in  this  way  to  the  discovery  of 
the  true  cause  of  the  disease. 

The  expression  "  negative  exploration  "  is  often  applied  to 
every  operation  in  search  of  renal  calculus  but  which  does  not 
result  in  the  discovery  of  a  stone.  This  expression  is  very 
misleading.  It  is  not  a  "negative  "  result  to  find  and  excise 
commencing  foci  of  tuberculous  disease ;  to  fix  a  misplaced  or 
freely  shifting  kidney ;  to  open  and  scrape  away  half  a  dozen 
small  abscesses  or  suppurating  cysts ;  to  excise  a  solid  renal  or 
perirenal  tumour,  or  a  tense  cyst ;  to  discover  and  give  exit  to 
blood,  extravasated  beneath  the  fibrous  capsule,  or  pent  up 
within  the  cavity  of  the  kidney ;  to  liberate  a  kidney  ham- 
pered by  tough  adhesions  (which  in  one  of  my  cases  were  as 
dense  and  hard  as  cartilage)  due  to  perinephritis,  pro- 
voked by  sprain  or  other  injury  or  disease ;  or  to  detect  and 
divide  an  ureteral  stricture  or  obstructing  valve.  Yet 
these  are  some  of  the  conditions  which  have  been  met 
with  in  the  search  for  stone  in  the  kidney,  and  which,  in 
many  instances,  have  been  most  successfully  cured. 


RENAL   CALCULUS.  47 

I  have  explored  several  cases  in  which  the  diagnosis  was 
very  doubtful,  but  the  severity  of  the  sufferings  so  intense 
that  the  patients  have  willingly  submitted  to  an  operation. 
The  exploration  has  proved  the  absence  of  a  calculus,  but 
has  revealed  a  degree  of  mobility  behind  the  peritoneum,  in 
what  I  have  designated  a  cinder-sifting  manner,  altogether 
out  of  proportion  to  any  mobility  detectable  by  clinical  ex- 
amination ;  in  some  of  them  no  mobility  whatever  could  be 
made  out  by  bimanual  abdominal  palpation.  In  these  cases, 
complete  relief  has  been  obtained  by  nephropexy. 

In  other  cases  I  have  found,  instead  of  calculus,  the 
kidney  more  or  less  displaced,  and  though  little,  if  at  all, 
movable,  yet  greatly  engorged  with  venous  blood,  owing  to  dis- 
tortion of  the  veins  at  the  hilum.  In  other  cases,  again,  the 
kidney  has  been  swollen  and  congested  with  venous  blood,  ob- 
structed by  the  pressure  of  tough  and  condensed  perinephric 
cellular  tissue.  Dr.  David  Newman  has  reported  a  case  of 
this  sort  (Trans.  Lond.  Clinical  Soc,  p.  67,  vol.  xxxvii.,  1897). 

The  relief  which  is  given  by  the  so-called  "  negative  ex- 
ploration," in  cases  such  as  I  have  referred  to,  is,  to  my  mind, 
a  striking  illustration  of  the  indirect  benefits  which  nephro- 
lithotomy has  conferred  on  suffering  humanity. 

Another  important  class  of  cases  in  which  the  symptoms 
simulate  renal  calculus,  is  ureteritis;  a  disease  to  which 
more  attention  has  been  given  both  in  France  and  Germany 
than  in  this  country  or  elsewhere.  As  long  as  nephrotomy 
was  limited  to  cases  in  which  the  kidney  is  converted  into  a 
great  abscess  swelling  the  ureter  was  never  seen  in  the  living 
human  body.  But  since  nephrolithotomy  took  its  place 
as  a  recognised  operation  ;  and  an  exploratory  incision,  with 
a  view  to  nephrolithotomy,  has  been  considered  justifiable, 
because  proved  to  be  safe,  the  morbid  states  of  the  ureter  have, 
by  degrees,  come  to  be  better  known,  and  operative  measures 
have  been  adopted  for  their  improvement  or  cure.  An  illus- 
trative case  of  this  sort  was  published  by  Israel  in  1893:* 
A  young  man  aged  twenty-eight  had  for  eight  years  suffered 
from  an  urinary  affection,  which  commenced  with  frequency 
of  micturition.  Soon,  to  this  symptom  was  added  acute 
attacks   of    pain    in    the    bladder,    and    left   renal   colic    of 

*  Berlin,  Klin.  Wochenschrift,  No.  27,  1893. 


48  HUNTEBIAN  LECTURES. 

extraordinary  violence.  He  became,  in  consequence,  almost  a 
morphia  maniac.  After  long  futile  treatment  elsewhere,  he 
came  under  Israel — thin,  miserable,  tormented  by  atrocious 
pains,  which  recurred  many  times  a  day.  The  clinical 
examination,  in  corroboration  of  the  patient's  account,  left 
no  doubt  as  to  the  presence  of  renal  calculus ;  there 
were  frequently  blood  and  mucus,  but  no  tubercle  bacilli 
present  in  the  urine ;  there  was,  too,  tenderness  in  the  left 
Hank,  and  pain  was  caused  by  pressure  upon  the  ureter 
throughout  its  abdominal  course.  Thus  Israel  felt  called 
upon  to  explore  for  calculus,  and  did  not  doubt  that  he 
would  find  one  in  the  kidney.  To  his  astonishment  there  was 
none.  He  found  the  kidney  small  and  soft ;  he  incised  its 
convex  border,  and  explored  the  renal  cavity  which  was  dilated. 
The  kidney  was  then  sutured,  the  wound  closed  and  rapidly 
healed,  but  without  any  amelioration  of  the  symptoms.  It 
therefore  seemed  clear  that  the  ureter  was  in  some  way  at 
fault,  and  Israel  determined  to  explore  it.  Cystoscopic  exa- 
mination showed  the  orifice  of  the  left  ureter  to  be  patent,  and 
the  bladder  free  of  growth ;  but  afforded  no  other  information. 

Two  months  and  a  week  after  the  first  operation  he  again 
explored  the  kidney,  with  negative  result,  and  then  through 
a  curvilinear  incision,  prolonged  towards  the  middle  of 
Poupart's  ligament,  he  discovered  that  the  ureter  throughout 
its  entire  length  was  extraordinarily  hard,  of  nearly  three 
times  its  normal  diameter,  and  presented  at  intervals  enlarge- 
ments of  quite  cartilaginous  consistence,  adherent  firmly  to 
the  surrounding  tissues,  especially  in  the  region  of  the  small 
pelvis.  It  was  permeable  from  kidney  to  bladder ;  but  there 
were  at  three  places  slight  obstructions,  due  to  thickened 
folds  of  mucous  membrane,  the  result  of  ureteritis.  The 
kidney,  small  and  hydronephrotic,  was  removed.  After  the 
nephrectomy,  the  colic  disappeared  immediately,  and,  al- 
though a  certain  amount  of  pain  persisted  for  eight  days 
along  the  course  of  the  ureter,  and  pus  was  detected  in  urine 
for  many  months,  the  patient  quite  recovered. 

Israel  makes  the  following  comment  upon  the  case :  "  I 
hope  if,  in  such  cases,  this  plan  of  procedure  is  followed  the 
number  of  instances  will  more  and  more  diminish,  to  ex- 
plain   which — in    the    event    of    no    satisfactory    cause    for 


RENAL   CALCULUS.  49 

the  painful  symptoms  being  ascertained — the  unmeaning 
diagnosis  'nephralgia'  is  made." 

I  join  with  Israel  in  hoping  that  fewer  cases  will  in  the 
future  be  set  down  to  nephralgia.  I  feel  sure  that  cases 
of  so-called  nephralgia  will  become  rarer  and  rarer,  (1)  if  due 
care  is  used  in  the  clinical  observation  of  patients  supposed  to 
be  suffering  from  renal  calculus  ;  (2)  if  proper  care  is  taken  in 
the  selection  of  cases  for  operation  ;  and  (3)  if  a  more  thorough 
and  methodical  examination  is  made  of  the  kidney  and  ureter 
than  is,  I  believe,  customary  at  present.  I  do  not  mean  to 
imply  that  a  calculus  will  be  found  in  every  case  in  which 
it  is  explored  for ;  far  from  it !  I  think,  on  the  contrary,  a 
greater  number  of  operations  will  be  done  than  hitherto,  in 
which  no  calculus  is  present.  But,  with  the  precautions  just 
mentioned,  these  operations  will  prove  to  be  negative  only  in 
so  far  as  calculus  is  concerned.  Other  conditions  will  be 
found,  sometimes  one,  sometimes  another,  which  the  opera- 
tion will  cure,  but  which  without  surgical  treatment  would 
have  remained  unrelieved,  or  have  grown  worse. 

It  must  be  borne  in  mind  that  the  case  Israel  described 
occurred  five  years  ago,  and  that  a  good  deal  of  progress  has 
been  made  in  ureteral  surgery  since  then.  With  the  more 
complete  examination  of  the  kidney  and  upper  end  of  the 
ureter,  by  eye  as  well  as  by  touch,  together  with  ureteral 
catheterisation,  which  ought  nowadays  to  be  employed,  the 
state  of  the  ureter  in  such  a  case  as  Israel's  could  be 
readily  ascertained,  and  would  be  treated  at  once  by  primary 
nephro-ureterectomy  by  Israel  himself,  or  any  surgeon  with 
experience  in  renal  operations,  unless  the  condition  of  the 
patient  rendered  a  somewhat  extensive  and  prolonged  opera- 
tion impossible  or  inexpedient. 

I  am  not  prepared  to  go  so  far  as  some  who  assert  that 
all  the  "  algias  "  are  a  cloak  for  ignorance ;  that  nephralgia 
or  renal  neuralgia  is  a  term  without  significance,  "an  ex- 
pression to  hide  our  inability  to  explain  the  cause  of 
paroxysmal  attacks  of  pain  in  the  renal  region." 

I  would  certainly,  with  others,  urge  the  necessity,  in  every 
case  in  which  one  is  tempted  to  adopt  this  diagnosis,  of  being 
very  watchful  not  to  overlook  anything  which  might  lead  to 
a  more  satisfactory  explanation. 


HUNTEBIAN  LECTURES. 

There  are  many  conditions  outside  the  kidney,  as  well  as 
those  connected  with  that  organ,  which  give  rise  to  symptoms 
suggestive  of  renal  calculus,  and  are  likely,  stone  being  dis- 
proved, to  be  set  down  to  nephralgia. 

I  have  known  instances  of  each  of  the  following  diseases 
being  the  subject  of  mistake :  (a)  Gastric  ulcer ;  (b) 
malignant  and  tuberculous  growths  in  the  intestines ;  (c) 
intestinal  adhesions,  whether  involving  the  renal  pedicle  or 
not;  (d)  aortic  or  cseliac  aneurysm  stretching  the  ureter  or 
renal  vessels ;  (e)  spinal  disease,  causing  perinephric  suppura- 
tion; (/)  vesical  calculus;  (g)  abscess,  and  calculus  in  the 
prostate;  (h)  growths  in  the  bladder;  (i)  ovaritis;  (j )  tuber- 
culous disease  of  the  Fallopian  tube;  (k)  a  gallstone  in  the 
cystic  duct. 

Still,  there  certainly  are  cases  in  which  neither  within 
nor  without  the  urinary  organs  has  anything  been  discovered 
to  explain  continuous  discomfort,  or  attacks  of  paroxysmal 
pain  in  the  renal  region  ;  and  yet  complete  relief  has  followed 
an  exploratory  operation.  These  are  the  cases  which  we  are 
apt  to  call  nephralgia ;  and  these  the  only  operations  which 
we  can  properly  speak  of  as  "  negative  explorations." 

Nor  do  I  think  we  must  quite  rely  upon  a  statement, 
which  has  been  put  forward  with  some  authority,  to  the 
effect  that  paroxysmal  renal  pain,  or  so-called  nephralgia,  is 
never  associated  with  neuralgia  in  other  situations,  and  has 
never  been  relieved  or  cured  by  anti-neuralgic  remedies. 

We  do  not  get  well-marked  cases  of  the  kind  in  this 
country,  nor  do  I  suggest  that  all  the  cases  of  renal  pain  which 
are  cured  by  renal  exploration  are  of  malarial  origin  ;  but 
nephralgia  of  malarial  origin  would  seem  to  be  known  in 
other  countries,  and  there  is  reason,  therefore,  for  thinking  it 
may  from  time  to  time  be  met  with  in  our  own,  in  persons 
who  have  lived  much  abroad. 

I  recall  a  short  but  suggestive  contribution  to  the  Medical 
Times  on  "  Nephralgia  due  to  Malarial  Poisoning,"  by  an  old 
pupil,  Mr.  F.  W.  Kirkham,  formerly  surgeon  to  the  Royal  West 
India  Mail,  and  whose  name  is  associated  with  a  most  success- 
ful case  of  ureterotomy  for  impacted  calculus.*  Mr.  Kirkham 
therein  reports  the  case  of  an  engineer  whom  he  was  called  to> 

'*  Medical  Times,  April  4th,  1885. 


RENAL    CALCULUS.  51 

see  when  at  Colon,  in  the  Isthmus  of  Panama,  who  had  twice 
suffered  from  intermittent  fever.  This  young1  man  (aged 
twenty-five)  was  seized  suddenly  with  severe  dull  aching  pain 
in  the  right  loin,  varied  at  intervals  by  paryoxysms  of  severe 
shooting  pains  extending  down  the  corresponding  thigh. 
After  lasting  about  four  hours  they  passed  off,  attended  by 
profuse  perspiration.  Similar  attacks  occurred  on  the  two 
following  days,  and  again  on  the  fourth  day,  when  he  was  first 
seen  professionally.  Mr.  Kirkham  found  the  temperature 
102-4°,  pulse  108,  skin  dry,  and  tongue  clean.  There  was  no 
enlargement  of  liver,  spleen,  or  kidney,  but  there  was  tender- 
ness in  the  right  loin.  The  urine,  though  alkaline,  was  free 
of  any  abnormal  sediment. 

Morphia  relieved  pain  and  promoted  sleep,  and  20  grs. 
of  quinine  prevented  the  recurrence  of  the  attack  on  the 
following  day,  and  15  grs.  of  the  anti-periodic  drug  had  the 
same  effect  on  the  day  after.  As  soon  as  the  quinine  was 
discontinued,  the  attacks  recurred,  but  a  return  to  the  quinine, 
and  subsequently  a  change  of  climate,  enabled  him  to  enjoy 
perfect  health.  Mr.  Kirkham  adds :  "  During  the  past  two 
years  I  have  had  four  patients  under  my  care  who,  after 
recovering,  or  during  their  recovery  from,  malarial  fevers,  have 
been  seized  with  daily  recurring  attacks  of  pain  in  the  region 
of  the  kidney,  presenting  symptoms  very  like  those  due  to 
the  passage  of  a  renal  calculus.  In  the  case  here  recorded,  it 
was  the  history  of  the  case,  the  previous  attacks  of  fever,  the 
periodical  recurrence  of  the  symptoms,  and  the  heightened 
temperature  during  the  paroxysms,  that  led  me  to  deem  it 
due  to  poisoning  from  malaria,  and  its  speedy  yielding 
to  the  anti-periodic  treatment  will,  I  think,  justify  me 
in  diagnosing  it  as  a  case  of  nephralgia  due  to  malarial 
poisoning." 

Tiffany  of  Maryland  (Trans.  Amer.  Surg.  Association,  vol. 
xii.,  p.  113,  1894)  speaks  of  having  seen  a  number  of  cases  of 
malarial  hematuria,  in  which,  it  would  seem,  a  history  of 
intermittent  or  remittent  fever  was  often  wanting,  but  the 
patients  had  a  sallow  complexion,  which  might  wrongly  have 
been  attributed  to  the  affection  for  which  surgical  relief  was 
sought.  His  remarks  lead  one  to  suppose,  though  he  does 
not  actually  say  so,  that  he  has  proved  the  malarial  origin 


52  HUNTEBIAN  LECTURES. 

of  the  hematuria  and  pigmented  urine  in  some  of  these 
cases,  by  finding  the  plasmodium  malarise  in  the  blood.  If 
renal  pain  be  associated  with  the  hematuria,  and  the  microbe 
of  malaria  be  not  looked  for,  or  not  found,  the  diagnosis  of 
renal  calculus  would  be  almost  sure  to  be  made. 

Another  ingenious  suggestion  to  explain  certain  cases 
which  simulate  renal  calculus  has  been  advanced.  Mr. 
Howard  Marsh  (Clinical  Trans.,  vol.  xxv.,  p.  195)  in  1892 
reported  the  case  of  a  woman,  aged  twenty-five,  who,  from  the 
age  of  thirteen,  suffered  pain  in  the  left  loin;  and,  when 
under  observation,  had  paroxysmal  attacks  of  pain,  pyuria, 
and  hsematuria.  Nephrectomy  was  followed  by  relief  of  these 
symptoms ;  the  left  kidney,  which  was  excised,  was  small, 
movable,  and  contained  three  stones  about  three  times  the 
size  of  a  grain  of  wheat.  Within  two  months  after  the 
operation  she  began  to  suffer  severe  pain  in  the  right  kidney, 
with  hsematuria  and  scanty  secretion  of  urine,  and  frequent 
and  painful  micturition — all  symptoms  which  are  suggestive 
of  renal  calculus.  The  case  further  simulated  stone,  because 
she  passed  a  small  calculus  on  one  occasion,  and  two  small 
pieces  of  calculous  material  on  another. 

This  affection  of  the  right  kidney  continued  for  over  four 
years,  during  which  time  the  right  kidney  and  ureter  were 
twice  explored  for  stone,  but  with  negative  result.  She  died 
after  the  second  exploratory  operation,  and  at  the  post- 
mortem examination  no  calculous  or  other  renal  condition 
was  found  to  explain  the  symptoms. 

Mr.  Marsh  suggests  that  the  case  is  one  of  the  nature  of 
Raynaud's  disease — a  neurosis,  in  which  there  is  exaggera- 
tion of  the  excito-motor  functions  of  the  spinal  cord,  just  as 
there  is  in  symmetrical  gangrene — and  that  the  symptoms 
are  due  to  a  profound  disturbance  of  the  vaso-rnotor  system 
of  the  kidney,  just  as  the  symmetrical  gangrene  is  to  ex- 
aggerated vaso-motor  disturbance  in  the  fingers  and  toes, 
and  other  peripheral  parts. 

If  this  view  of  the  occasional  causation  of  symptoms, 
which  are  usually  regarded  as  pathognomonic  of  stone  in 
the  kidney,  be  correct,  it  may  have  considerable  importance 
in  explaining  certain  cases  of  mistaken  diagnosis  which  at 
present  are  inexplicable. 


"  UNSUSPECTED  RENAL   CALCULUS:'  5;J 

There  are,  however,  difficulties  in  the  way  of  accepting  it 
as  the  explanation  of  the  case  in  point,  namely : 

(1)  There  was  in  this  case  unquestionable  proof  of  small 
calculi  in  each  kidney. 

(2)  There  was  a  little  dilatation  of  the  right  ureter,  which 
was  bound  down  by  fibrous  tissue  near  the  caecum. 

(3)  There  were  general  adhesions  in  the  right  iliac  fossa, 
and  an  open  ulcerated  appendix  cseci. 

(4)  There  were  many  old  adhesions  around  the  uterus, 
fixing  it  to  the  neighbouring  parts. 

(5)  The  right  kidney,  described  as  "large  and  pale,  but 
otherwise  healthy,"  does  not  seem  to  have  been  submitted  to 
microscopical  examination. 

To  me  it  would  seem  more  probable  that  the  vaso-motor 
disturbance  (if  this,  and  not  chronic  interstitial  nephritis,  was 
the  cause  of  the  symptoms)  was  not  an  idiopathic  disturb- 
ance, but  was  due  to  the  irritation  of  calculous  particles ;  of 
the  fibrous  adhesions  near  the  caecum  ;  and  of  the  old  adhesions 
about  the  uterus.  That,  in  fact,  there  existed  a  combination 
of  causes  of  irritation  of  the  vaso-constrictor  nerves  of  the 
kidney  and  ureter  which  produced  pain,  hematuria,  and 
reflex  suppression  of  the  function  of  the  kidney ;  in  other 
words,  that  the  nature  of  the  case  was  the  same  as  the 
paroxysmal  attacks  of  renal  colic  due  to  irritation  by  stone. 

Hopes  were  entertained  that  the  Rontgen  rays  would  be  of 
service  in  determining  the  presence  or  absence  of  renal  calculi, 
but  hitherto  they  have  afforded  but  little  help  in  this  direc- 
tion. In  time,  possibly,  they  will  be  able  to  render  more 
assistance  than  heretofore ;  but  if  thejr  demonstrate  with 
certainty  the  presence  of  a  calculus  without  being  also  able 
to  reveal  the  other  morbid  conditions  remediable  by  opera- 
tion, which  mimic  calculus,  they  will,  I  fear,  be  the  means 
of  putting  back  renal  surgery  by  deterring  many  patients 
from  submitting  to  surgical  explorations,  who  can  be  cured 
by  no  other  treatment  than  an  operation. 

"  UNSUSPECTED    RENAL    CALCULUS." 

I  have  pointed  out  that  there  are  numerous  morbid 
conditions  other  than  renal  calculus  which  cause  typical  renal 


54  HTJNTERIAN  LECTURES. 

colic.  Conversely,  there  are  many  cases  in  which  the  symp- 
toms, due  to  renal  or  ureteral  calculus,  are  not  referred  to  the 
kidney  or  ureter  at  all,  but  to  some  other  organ.  It  is  also 
well  known  that  a  calculus  for  a  long  time  may  cause  no 
symptoms  whatever. 

If  such  silent,  lurking  calculi  could  be  discovered  and 
removed,  many  deaths  from  calculous  anuria,  much  illness 
and  suffering  from  perinephric  abscesses  and  renal  fistulse, 
and  many  kidneys  gradually  undergoing  atrophy  or  dis- 
organisation, might  be  saved  by  well-timed  operation. 

Unsuspected  calculi  group  themselves  into  two  classes — 
those  which  do  not  excite  symptoms ;  and  those  which  cause 
symptoms  which  are  not  referred  to  the  kidney  or  ureter. 

A.  Calculi  which  do  not  cause  symptoms. — I  might  quote 
several  cases  in  which  a  calculus,  after  existing  for  years,  has 
set  up  perinephric  abscess,  without  having  previously  caused 
any  definite  renal  symptoms  A  typical  case  of  the  kind  is 
recorded,  and  the  calculus  illustrated  on  pages  220  and  221 
of  my  book  "  Surgical  Diseases  of  the  Kidney  "  (1885). 

A  calculus  may  grow  silently  to  such  a  size  as  to  be  felt 
on  palpating  the  abdomen  without  causing  any  subjective 
symptoms. 

I  have  met  with  three  or  four  such  cases.  I  will  epitomise 
one  of  them. 

In  May,  1894, 1  saw  a  Mrs.  B.,  aged  twenty-seven  (with  Dr. 
Ford  Anderson),  who  for  two  or  three  years  had  suffered  from 
pain  and  sense  of  weakness  in  her  back,  more  especially  in  the 
left  side.  The  urine  had  never  contained  blood  so  far  as  she 
knew ;  she  had  never  suffered  from  frequent  or  painful  mic- 
turition, nor  had  there  been  any  noticeable  variations  in  the 
amount  of  urine  excreted.  She  had  gone  into  society,  and 
danced,  without  more  inconvenience  than  a  rather  undue 
sense  of  fatigue  afterwards. 

About  four  weeks  before  I  saw  her  she  began  to  pass 
muco-pus  in  alkaline  urine  ;  and  five  days  before,  she  was 
seized  with  violent  pain  in  the  left  renal  region,  which  lasted 
many  hours,  in  spite  of  morphia  injections. 

Following  upon  this  attack  were  several  rigors,  a  tem- 
perature of  105°,  more  or  less  continuous  pain  in  the  left 
side,  and  some  fulness  in  the  left  flank.      Dr.  Anderson  now 


"UNSUSPECTED    RENAL    CALCULUS."  55 

had  a  consultation  with  Dr.  Fenwick ;  and  on  the  following 
day  I  saw  her  with  the  view  to  an  operation. 

She  was  extremely  ill  with  a  hectic  flush  on  her  cheeks, 
widely  dilated  pupils,  a  small,  rapid,  weak  pulse, a  furred  tongue, 
and  very  marked  nervous  depression  and  anxiety.  She  com- 
plained of  pain  over  the  left  kidney ;  but  had  never  felt  pain, 
and  was  quite  unaware  of  anything  wrong  in  the  right  kidney. 
There  was  no  pain  elsewhere,  though  she  replied,  in  answer  to 
questions  on  this  point,  that  "  she  felt  as  though  she  might 
have  pain  any where." 

There  was  no  tenderness  about  the  right  kidney,  and  little 
if  any  about  the  left ;  but  the  left  could  easily  be  made 
out  by  bimanual  examination,  and  was  felt  to  be  rather 
larger  than  normal. 

On  the  right  side  there  was  a  hard,  irregular  swelling 
plainly  to  be  felt  in  the  loin  and  through  the  anterior 
abdominal  parietes.  The  antero-internal  margin  of  this  hard 
lump  was  bluntly  conical,  and  the  apex  of  the  cone  had 
a  projecting  rim  surrounding  a  little  ball  the  size  of  a  pea. 
In  front  of  the  lump  there  was  resonance,  but  not  behind  it. 
The  tumour  did  not  make  the  loin  in  the  least  prominent, 
but  it  could  be  readily  pushed  from  before  backwards. 
It  had  very  little  movement  in  the  vertical  or  side-to-side 
directions. 

The  position  of  the  lump  as  felt  from  in  front  was 
distinctly  below  the  liver ;  the  bulk  of  the  kidney  being 
situated  about  midway  between  the  border  of  the  thorax 
and  the  anterior  superior  spine  of  the  ilium,  and  its  lower 
end  and  inner  border  being  continuous  with  the  hard 
mass.  It  scarcely  moved  on  deep  inspiration,  but  fell  for- 
wards and  almost  projected  the  anterior  abdominal  wall  in 
the  knee  and  elbow  posture.  The  temperature  on  the 
morning  of  my  first  visit  (May  16th)  was  101°  F.  ;  overnight  it 
had  been  105°  F.  Some  urine,  passed  during  the  visit,  was 
alkaline,  of  a  muddy  yellow  colour  and  gave  marked  reaction 
of  albumin.  Microscopically  there  were  numerous  pus  cor- 
puscles, a  little  blood,  some  epithelium  like  that  of  the  renal 
pelvis,  and  many  rhomboid  crystals  of  triple  phosphates. 

Through  an  incision  in  the  right  semilunar  line  the  left 
kidney  was  made  out  to  be  larger  and  more  globular  in  form 


56  HTJNTERIAN  LECTURES. 

than  normal;  it  was  not  soft  or  flaccid,  nor  could  any 
calculus  be  felt  in  it.  It  was  quite  impossible  to  be  sure 
that  the  enlargement  was  due  to  anything  other  than 
simple  hypertrophy.  Had  it  had  the  feeling  of  a  hydro- 
nephrotic  kidney,  or  of  a  calculus,  I  should  at  once  have 
opened  it  through  the  left  loin. 

At  the  inner  and  lower  border  of  the  right  kidney  was 
felt  a  lump  which  was  obviously  a  large  calculus  filling  the 
infundibulum  and  projecting  into  the  upper  part  of  the 
ureter. 

Through  an  oblique  incision  in  the  right  loin,  a  calculus 
weighing  830  grains  was  removed ;  it  had  several  branches 
extending  in  different  directions  into  the  substance  of  the 
lower  portion  of  the  kidney  and  to  which  the  renal  substance 
was  intimately  adherent.  When  the  lower  half  of  the  kidney 
and  the  tumour  were  thoroughly  exposed  to  view,  I  cut 
through  a  thin  layer  of  renal  tissue  at  quite  the  lower  end  of 
the  kidney.  With  my  finger  I  freed  a  great  part  of  the 
calculus  and  drew  it  out  of  the  wound ;  it  was  then  seen 
that  the  bulk  of  the  calculus  was  covered  by  a  distinct  fibrous 
capsule,  which  had  to  be  incised  and  literally  peeled  off  the 
calculus.  This  capsule  proved  to  consist  of  the  renal  pelvis 
and  the  dilated  upper  end  of  the  ureter,  which  were  drawn 
out  through  the  incision  in  the  renal  parenchyma  with  the 
stone,  much  like  a  glove  is  pulled  inside  out  with  the  finger 
tip  still  in  its  stall.     No  pus  was  seen  during  the  operation. 

A  small  piece  of  the  renal  secreting  substance  which  was 
torn  away  with  the  calculus  was  examined  microscopically. 
It  showed  that  there  had  been  chronic  irritation  and  increased 
tension  within  the  urinary  tubules ;  and  arterio- sclerotic 
changes  in  the  organ.  Marked  infiltration,  with  round  and 
oval  cells,  of  the  interstitial  tissue  and  Malpighian  tufts 
was  evident.  The  glomerular  capsules  were  much  thickened 
and  their  epithelial  lining  greatly  proliferated.  In  places 
the  glomeruli  were  undergoing  hyaline  degeneration.  The 
arteries  showed  marked  thickening  of  their  inner  and 
adjacent  parts  of  their  middle  coats.  There  was  fatty 
degeneration  of  the  epithelium  of  the  convoluted  tubules, 
and  in  places  the  tubules  were  obliterated  by  the  interstitial 
overgrowth.     The  straight  tubes  were  dilated  and  in  many 


"  UNSUSPECTED    RENAL    CALCULUS"  57 

cases  were  Avithout  epithelium.  Here  and  there  patches  of 
the  renal  tissue  were  undergoing  coagulation  necrosis. 

No  sutures  were  used  for  closing  the  wound  in  the 
infundibulum  and  ureter,  because  their  walls  seemed  too  thin, 
from  overstretching,  to  hold  them.  The  patient  recovered 
very  well  from  the  operation,  but  with  an  urinary  fistula  ; 
and  the  urine  which  was  passed  by  the  urethra  remained 
unaltered  in  character,  viz.  sp.  gr.  1010  alkaline,  and  having 
a  muco-purulent  deposit,  which  under  the  microscope  showed 
blood,  pus,  crystals  of  oxalate  of  lime,  triple  phosphates,  and 
numerous  staphylococci.  I  was  therefore  compelled  to  the 
conclusion  that  there  was  a  calculus  in  the  left  kidney  which 
had  been  the  real  cause  of  the  left-sided  pain  and  feverish 
symptoms,  and  was  still  keeping  up  suppuration  in  the  left 
renal  cavity.  This  opinion  was  confirmed,  and  hopes  of  per- 
manent recovery  were  encouraged,  by  the  fact  that  three 
months  after  the  operation — viz.  in  August,  1894 — after  three 
hours  of  severe  paroxysmal  pain  in  the  left  renal  region,  a 
stone  the  size  of  a  small  nutmeg  was  voided  naturally.  The 
subsequent  course  of  the  case  was  very  disappointing  and 
distressing,  and  may  be  briefly  summarised  as  follows : 

As  the  right-sided  fistula  continued,  a  second  operation  was 
performed — on  November  28th,  1894 — upon  the  right  kidney, 
and  two  small  calculi,  and  what  looked  like  a  fragment  of  the 
original  calculus,  were  removed  from  the  upper  end  of  the 
right  ureter,  just  beyond  its  junction  with  the  renal  pelvis. 
The  fistulous  track  led  directly  down  to  an  opening  in  the 
pelvis  of  the  kidney,  and  thus  to  these  calculi.  Several 
drachms  of  stinking  pus  were  evacuated  from  the  upper  part 
of  the  kidney  through  an  incision  in  the  convex  border.  The 
interior  of  the  kidney  was  well  irrigated,  a  drain  tube  was 
introduced,  and  the  parietal  wound  closed  by  sutures. 

Much  improvement  followed  this  operation,  but  the  fistula 
did  not  close  ;  and  the  urine  passed  per  vices  naturales  (about 
thirty  ounces  per  day)  always  contained  pus.  Improvement 
was  maintained  till  Monday,  January  21st,  1895,  when,  for  the 
first  time  since  August,  when  the  calculus  was  passed  b}^  the 
urethra,  she  was  seized  with  great  pain  in  the  left  renal 
region,  and  had  a  high  temperature.  The  relation  of  pain  to 
micturition   was    this :    one   ounce   of  urine    was   passed   at 


58  HUNTERIAN  LECTURES. 

10  a.m. ;  at  4  p.m.  it  was  thought  a  little  more  urine  was 
voided  when  the  bowels  acted ;  at  5  p.m.  pain  commenced,  at 
first  of  a  dull  aching  character,  then  increasing  in  intensity, 
with  a  feeling  of  fulness  in  the  left  loin.  All  through  the  night 
of  January  21st  and  the  following  day  and  night,  scarcely  any 
urine  was  passed  naturally,  and  the  pain  continued  very 
severe.  On  the  morning  of  the  23rd  at  5.30,  four  and  a  half 
ounces  were  passed ;  at  8.30,  six  ounces ;  at  10  o'clock,  six 
ounces ;  and  so  onwards ;  and  the  pain  gradually  passed  off. 
During  the  hours  when  scarcely  any  urine  was  being  passed 
by  the  urethra  there  was  a  free  flow  of  urine  through  the 
fistula  in  the  right  loin. 

On  Friday,  January  25th,  a  very  similar  attack  came  on,  but 
was  of  shorter  duration,  and  passed  off  with  the  re-establish- 
ment of  the  secretion  of  urine  by  the  left  kidney  on  the 
evening  of  the  next  day,  January  26th.  During  both  these 
attacks  there  was  distinct  fulness  and  hardness  of  the  abdo- 
minal muscles  over  the  left  kidney. 

The  urine  passed  by  the  urethra  during  these  attacks  was 
very  thick  and  offensive,  and  contained  much  pus.  It  was 
not  certain  whether  the  small  amount  of  urine  voided  during 
these  attacks  came  from  the  right  kidney,  or  from  the  left ; 
but  it  was  quite  clear  that  the  right  kidney  was  doing  fair 
work,  whilst  the  action  of  the  left  was  believed  to  be  all 
but  suppressed,  and  the  left  ureter  partially  or  entirely 
occluded. 

On  February  2nd,  1895,  another  similar  attack  commenced, 
only  ten  ounces  of  urine  being  passed  naturally ;  on  February 
3rd,  only  six  and  a  half  ounces  was  passed ;  on  February  4th, 
only  one  ounce,  and  none  subsequently.  On  February  7th,  I  was 
again  consulted,  and  I  found  the  patient  with  flushed  hollow 
cheeks,  small  feeble  pulse,  an  urinous  odour  in  the  breath,  a 
subnormal  temperature,  vomiting,  and  complete  loss  of  appe- 
tite. There  was  a  large  tumour  on  the  left  flank.  I  told  the 
friends  the  patient  was  rapidly  sinking,  and  would  soon  die 
if  the  cause  of  the  obstruction  hi  the  left  kidney  was  not 
removed ;  that  an  operation  afforded  the  only  possible  chance, 
and  that  a  very  slight  one,  considering  the  advanced  degenera- 
tion of  the  parenchyma  of  the  left  kidney,  and  the  prolonged 
anuria.    Sanction  was  given  for  the  operation  on  the  following 


"  UNSUSPECTED    UENAL    CALCULUS."  59 

day  (February  8th),  and  then  it  was  ascertained  that 
the  kidney  was  almost  entirely  destroyed.  After  cutting 
through  the  thin  abdominal  walls,  the  kidney,  which  was 
tightly  distended  and  bulging  against  the  fascia,  ruptured  as 
soon  as  the  support  was  removed  by  incising  the  fascia. 
Between  2  and  3  pints  of  the  most  foetid  purulent  urinous 
fluid  escaped,  then  with  my  finger  within  the  renal  pelvis,  I 
extracted  an  elongated  almond-sized  calculus,  which  was 
tightly  plugging  the  upper  end  of  the  ureter.  The  kidney 
was  enormously  sacculated,  and  a  large  branched  calculus 
was  removed  in  three  fragments  from  some  of  the  upper 
sacculi.  The  interior  of  the  kidney  was  flushed  with  warm 
water  and  drained,  and  the  wound  closed.  The  operation 
occupied  less  than  three-quarters  of  an  hour.  Brandy  and 
strychnine  were  administered,  but  the  patient  never  rallied, 
and  died  the  same  afternoon. 

It  was,  I  believe,  little  more  than  a  coincidence  that  after 
the  first  operation  on  her  right  kidney,  the  patient  lost  all  her 
pain  on  her  left  side ;  and  on  the  second  day  felt  so  much 
better  that  she  described  herself  as  feeling  "  quite  a  different 
being." 

I  think  the  relief  she  felt  was  owing  to  the  stone,  which  was 
blocking  the  left  ureter,  slipping  back  into  the  renal  pelvis 
during  the  movements  requisite  for  the  operation,  or  under 
the  relaxing  influence  of  the  anaesthetic. 

It  was  plain,  for  the  following  reasons,  that  the  pus  in 
the  urine,  both  before  and  after  the  nephrolithotomy,  must 
have  come  from  the  left  kidney :  (1)  the  urine  remained  un- 
changed by  the  operation  ;  (2)  the  right  ureter  was  com- 
pletely blocked  before  the  operation  by  the  large  stone 
removed,  and  to  which  the  whole  infundibulum  was 
tenaciously  adherent;  (3)  after  the  operation  all  the  urine 
secreted  by  the  right  kidney  escaped  through  the  lumbar 
wound ;  (4)  there  was  no  pus  found  about  the  stone  in  the 
right  kidney. 

It  is  also  equally  certain  that  the  calculi  which  were, 
later  on,  removed  from  the  left  kidney  had  been  the 
cause  of  the  feverish  and  nervous,  as  well  as  of  the  urinary, 
symptoms;  and  that  I  had,  so  to  speak,  operated  upon  the 
wrong  organ. 


60  HUNTEBIAN  LECTURES. 

This  arose  through  my  following  the  teaching,  to  which  a 
good  deal  of  importance  was  attached  by  the  distinguished 
operator  who  originated  it,  namely,  that  a  stone  in  one  kidney 
may  cause  pain  to  be  referred  to  the  opposite  kidney,  without 
itself  being  the  seat  of  pain ;  and  that  if  the  abdominal  route 
is  taken,  we  shall  be  able  to  avoid  operating  upon  the  wrong 
kidney,  by  finding  out  by  direct  palpation  in  which  organ  the 
stone  is  really  situated. 

In  this  particular  case,  coeliotomy  was  not  needed  to  dis- 
cover the  stone  in  the  right  kidney ;  this  was  ascertained  at  the 
bedside.  On  the  other  hand,  it  did  not  enable  me  to  ascer- 
tain that  the  left  kidney  contained  one  large  branched 
calculus,  and  two  others  of  smaller  size  which  I  removed  at 
a  subsequent  operation,  nine  months  after  the  first ;  nor 
a  calculus  which  was  passed  naturally  from  the  same 
kidney,  during  convalescence  from  the  first  operation  on 
the  right  kidney. 

The  left  kidney,  with  the  hand  in  the  abdominal  cavity, 
was  felt  to  be  enlarged,  more  or  less  ^lobular,  and  of  uniform 
firmness.  It  was  very  carefully  palpated  for  stone,  but  nothing 
was  felt  beyond  what  was  consistent  with  simple  hypertrophy. 

Fifteen  years  ago,  in  a  paper  published  in  the  Royal 
Medical  and  Chirurgiccd  Transactions  (vol.  lxviii.,  p.  75 
et  seq.),  I  called  attention  to  the  uncertainty  of  ascertaining 
the  presence  of  a  calculus  by  direct  palpation  of  the  kidney, 
either  with  the  hand  in  the  abdominal  cavity,  or  after  the 
kidney  had  been  removed  from  the  body.  In  the  Clinical 
Society's  Transactions  of  1887  (vol.  x.,  p.  109)  I  again 
referred  to  the  same  probability  of  error.  Further  experience 
has  convinced  me  of  the  fallacy  of  this  mode  of  examination, 
and  I  would  lay  it  down  as  an  axiom,  that  the  kidney  which 
ought  to  be  first  explored  is  the  one  on  the  painful  side. 

I  shall  refer  further  on  (pp.  65  and  101)  to  a  case  of  calculous 
anuria,  in  which  calculi  could  be  felt  through  the  abdominal 
wall  in  the  right  kidney,  but  the  attacks  of  pain  associated 
with  the  anuria  were  referred  to  the  left  kidney.  I  operated 
upon  the  painful  side,  found  a  small  stone  in  a  large,  hyper- 
trophied  kidney,  and  the  paroxysms  of  pain  and  anuria  ceased 
entirely,  and  the  kidney  which  was  doing  all  the  work  was 
thus  saved  from  advancing  destruction. 


"  UNSUSPECTED    RENAL    CALCULUS/'  61 

I  have  been  once  or  twice  tempted  to  follow  the  teaching 
of  the  surgeon  referred  to,  but,  excepting  on  this  one 
occasion,  I  have  resisted.  In  Case  No.  9,  Table  L,  the  in- 
ducement was  very  strong.  The  nature  of  this  case  was,  in 
many  respects,  similar  to  the  one  I  have  just  related.  I  was 
able  to  feel  a  stone  in  the  right  kidney  through  the  abdominal 
walls.  I  removed  it  through  the  right  loin  ;  it  weighed  1,303 
grs.  The  young  woman  recovered,  with  an  urinary  fistula. 
Nearly  twelve  months  afterwards  she  returned,  complaining 
of  terrible  pain  in  the  left  kidney,  but  none  in  the  right.  At 
a  consultation  with  several  of  my  colleagues,  the  opinion  held 
was  that  the  left-sided  pain  was  reflected  from  the  right 
kidney;  and  that  right  nephrectomy  should  be  done,  more 
especially  as  this  operation  would  get  rid  of  the  fistula  in  the 
right  loin.  Not  believing  in  this  kind  of  reflected  pain,  I  ven- 
tured to  act  contrarily  to  this  opinion.  I  explored  the  painful 
kidney,  and  extracted  therefrom  a  stone  weighing  513  grs.  The 
girl  rapidly  recovered  from  the  operation.  Fifteen  months 
later  I  removed  the  right  kidney,  because  it  became  distended 
and  suppurated.  The  patient  recovered  well,  and  was  cured 
of  the  sinus  in  the  right  loin.  Sixteen  months  after  this  last 
operation  (the  nephrectomy)  she  was  known  to  be  in  good 
health ;  her  left  kidney,  from  which  the  stone  of  513  grs. 
had  been  extracted,  discharging  its  excreting  functions  well. 
One  is  tempted  to  ask,  "  What  would  have  happened  had  I 
nephrectomised  the  right  kidney  before  freeing  her  left 
kidney  of  the  calculus  ? "  My  own  experience  of  nephrectomy 
in  other  cases  where  there  was  a  stone  in  the  opposite  kidney, 
compels  me  to  answer  "  Probably,  death." 

There  is  not,  so  far  as  I  know,  any  case  on  record  in 
which  there  is  completely  satisfactory  evidence  of  symptoms 
on  one  side  only  being  caused  by  a  stone  in  the  kidney  of 
the  opposite  side.  The  presence  of  a  stone  on  one  side  is 
not  .proof  that  the  opposite  and  painful  side  is  not  also 
affected.  That  the  attacks  referred  to  one  side  have  ceased 
after  operating  upon  the  opposite  and  painless  side  is  not 
conclusive.  This  may  be  a  coincidence,  and  due  to  the 
accidental  shifting  of  a  calculus  in  the  painful  kidney,  or 
to  some  other  cause. 

Of  course  it  may  happen  that  with  a  great  deal  of  disease 


62  HUNTERIAN  LECTURES. 

on  the  painful  side  there  may  be  silent  or  quiescent  disease 
on  the  opposite  side,  as  in  the  cases  I  have  just  quoted,  and 
this  quiet  disease  may  be  so  advanced  as  to  cause  a  fatal 
issue  after  operating  on  the  painful  side ;  but  this  is  an 
entirely  different  question.  In  several  of  the  fatal  cases  in 
my  lists  of  nephrotomy  and  nephrectomy  for  stone  the 
opposite  kidney  has  been  proved,  by  post-mortem  examina- 
tion, to  be  disorganised  by  unsuspected  calculus.  This  was 
so  in  cases  in  Nos.  11  and  22,  Table  II. ;  in  No.  4,  Table 
III. ;  and  was,  I  have  no  doubt,  so,  though  not  verified  by 
post  mortem,  in  No.  15,  Table  III. 

It  may  be  asked,  "  Is  it  consistent  to  reject  the  theory 
of  transferred  or  reflected  pain,  as  applied  to  the  opposite 
kidney,  and  yet  to  accept  it  when  applied  to  the  bladder  or 
to  the  ovary  ? "  Well,  I  believe  it  is  so.  I  have  verified 
the  one  and  have  not  seen  any  proof  of  the  other.  I  do 
not  attempt  a  full  explanation  of  this  ;  but  I  Avould  point 
out  that  there  are  instances  of  a  nerve  connection  between 
parts  on  the  same  side  of  the  median  line  more  direct  than 
between  similar  organs,  or  parts,  on  the  opposite  sides  of 
the  body. 

Take,  for  example,  hip  disease — how  often  does  it  give 
rise  to  reflected  or  transferred  pain  in  the  opposite  hip-joint  ? 
Yet  it  is  not  rare  for  it  to  cause  pain  in  the  knee  of  the 
same  side.  How  often  does  a  decayed  molar  cause  pain 
in  the  sound  molars  of  the  opposite  side  ;  or  an  obstinate 
ulcer  on  one  edge  of  the  tongue  cause  pain  in  the  healthy 
tissue  of  the  opposite  edge  ?  Yet  the  decayed  tooth  will 
keep  up  eczema  in  the  ear  hole  of  the  same  side,  and  the 
lingual  ulcer  racking  pain  there,  so  long  as  the  tooth  is  not 
extracted  and  the  ulcer  not  healed. 

The  eye  is  often  quoted  as  a  parallel  with  the  kidney  in 
this  respect,  but  the  anatomical  relations  of  nerves  and 
vessels  respectively  of  the  two  eyes  are  quite  different  from 
those  in  the  case  of  the  kidneys. 

The  anatomical  communications  between  the  kidney  and 
the  bladder,  and  between  the  kidney  and  uterus,  as  well  as 
between  the  kidney  and  ovary  and  Fallopian  tube  of  the 
same  side,  are  much  more  important  from  the  point  of  view 
of    transferred    impressions    than    those    between    the    two 


"  UNSUSPECTED    RENAL    CALCULUS."  63 

kidneys.  The  half  of  the  bladder  may  be  regarded  as  an 
expansion  of  the  lower  end  of  the  renal  duct  of  the  same 
side ;  and  any  irritation  from  a  cause  seated  in  the  kidney 
may  be  conveyed  to  it  by  continuity  of  structures.  The 
blood  vessels  to  the  ovary  and  tube,  as  well  as  the  uterine 
vessels,  are  in  close  relation  with  the  ureter  of  the  same  side. 
Moreover,  the  ureter  has  a  considerable  course  within  the 
folds  of  the  broad  ligament,  and  not  far  removed  from  the 
neck  of  the  uterus ;  and  any  drag  or  tension  on  the  cellular 
tissue  within  the  ligamentous  folds  is  calculated  to  irritate 
the  ureter  or  vice  versa. 

I  have  no  doubt  that  movable  kidney  causes  certain 
uterine  and  ovarian  symptoms;  and  in  some  cases  of  very 
great  mobility  of  kidney  I  have  felt  a  greatly  thickened  and 
tender  ureter  through  the  vaginal  roof.  In  one  case  it  was  so 
thickened  and  indurated  that  it  felt  like  an  elongated  stone. 
It  is  acknowledged  that  some  movable  kidneys,  and  I  believe 
also  some  kidneys  not  movable,  swell  and  ache  during 
the  catamenial  period :  in  a  case  within  my  knowledge  a 
movable  kidney  did  so  to  the  extent  of  being  mistaken  for  a 
malignant  renal  tumour  by  a  very  noted  obstetric  physician. 
The  kidney  also  occasionally  undergoes  grave  and  even 
alarming  inflammatory  processes  during  the  early  months  of 
pregnancy,  even  where  there  is  no  peri-uterine  inflammation ; 
and  did  time  permit  I  would  quote  cases  in  proof. 

In  parametric  and  perimetric  inflammations,  albuminuria 
and  pyuria  are  far  from  rare,  and  may  assume  alarming  pro- 
portions. They  occur  in  non-puerperal  as  well  as  puerperal 
cases,  though  much  more  frequently  in  the  puerperal.  These 
urinary  changes  are  not  due  to  vesical,  but  to  renal  conditions  ; 
occur  during  the  parametric  and  perimetric  affections,  and 
subside  with  thern.  And  as  showing  the  influence  of  the 
peri-uterine  cellular  tissue  upon  the  ureter  and  through  the 
ureter  to  the  kidney,  I  may  point  to  the  fact  that  in  the  late 
Matthews  Duncan's  experience  (Med.  Chir.  Trans.,  vol.  xlvii. 
p.  274)  albuminuria  is  much  more  frequently  associated  with 
parametritis,  i.e.  inflammation  in  the  pelvic  cellular,  than  with 
perimetritis,  i.e.  inflammation  of  the  peritoneum  of  the  broad 
ligaments  and  uterus.  It  is  also  well  known  that  in  para- 
metritis the  inflammatory  process  has  a  strong  preference  for 


64  HUNTERIAN  LECTURES. 

spreading  along  the  ureter  to  the  kidney ;  and  having  done 
so,  not  rarely  gives  rise  to  perinephric  abscess. 

B.  Unsuspected  calculi  with  symptoms  transferred  to 
other  organs. — If  the  reasons  above  stated  are  correct,  there 
is  no  cause  for  surprise  that  with  renal  calculus,  as  with 
vesical  calculus,  hip-joint,  and  spinal  diseases,  pain  may  be 
referred  to  a  distant  part  instead  of  to  the  organ  affected. 

In  renal  calculus  the  symptoms  may  be  referred  to  the 
bladder,  ovary,  uterus,  or  testicle,  instead  of  to  the  kidney. 

I  am  constantly  seeing  cases  of  renal  calculus  and  other 
renal  diseases  which  have  been  under  prolonged  and  repeated 
treatment  for  cystitis.  Bladders  are  frequently  sounded, 
irrigated,  injected  with  solutions  of  silver  nitrate,  and  other- 
wise actively  treated,  without  apparently  the  least  suspicion 
that  the  trouble  is  due  to  stone  in  the  kidney.  I  will 
mention  one  very  striking  instance,  in  which  for  nearly  ten 
years  all  symptoms  pointed  to  the  bladder,  none  to  the 
kidney ;  but  at  length  a  renal  calculus  was  removed,  and  the 
patient  regained  perfect  health. 

A  married  woman  (No.  19,  Table  I.),  aged  thirty-five,  lead- 
ing an  active  life,  and  of  a  physically  and  mentally  healthy 
constitution,  had  suffered  from  very  painful  micturition,  cystitis, 
and  frequent  phosphatic  concretions  in  the  bladder  for  two 
years.  All  the  tried  remedies  having  failed  to  give  relief,  a 
vesico-vaginal  fistula  was  established  by  operation,  and  the 
urine  was  allowed  to  flow  away  continually  into  an  urinal.  This 
state  of  things  went  on  for  some  years,  and  then  the  vesico- 
vaginal fistula  was  closed.  No  sooner  had  this  been  success- 
fully accomplished  than  all  the  old  symptoms  returned,  so 
that  in  two  or  three  months  the  fistula  had  to  be  re-established. 
In  this  condition  the  patient  passed  over  nine  of  the  best 
years  of  her  womanhood.  Then  some  pain  and  some  extra 
resistance  were  experienced  in  the  right  renal  region,  and 
after  four  or  five  months'  duration  I  was  asked  to  see  her 
by  Dr.  Fenton,  who  had  diagnosed  right  renal  calculus.  I 
endorsed  this  opinion,  and  on  May  14th,  1893,  I  removed  a 
small  lozenge-shaped  uric  acid  calculus  weighing  only  4  grs., 
through  an  incision  in  the  convex  border  of  the  kidney. 
The  patient  made  an  uninterrupted  recovery ;  and  when  quite 
convalescent  from   the   nephrolithotomy,  Dr.  Fenton  closed 


"  UNSUSPECTED    RENAL    CALCULUS."  65 

the  vesicovaginal  fistula.  The  patient  remains  well  to  this 
day,  has  perfect  control  over  her  urine,  and,  as  she  expresses 
it,  "  finds  her  life  quite  a  different  thing,  and  is  now  well 
worth  living." 

It  is  sometimes  the  same  with  the  ovary  as  with  the 
bladder  ;  it  receives  all  the  attention  and  treatment,  whilst 
the  cause  of  the  trouble  is  in  the  kidney.  I  altogether  exclude 
in  these  remarks  cases  in  which  there  is  some  morbid,  organic 
or  functional  state  of  the  ovary  as  well  as  of  the  kidney.  I 
refer  exclusively  to  instances  in  which  pain,  either  paroxysmal 
or  constant,  is  referred  to  the  healthy  ovary,  not  to  the  kidney, 
and  may  be  associated  with  tenderness  in  the  hypogastrium, 
or  per  vaginam,  and  yet  is  caused  by  renal  calculus  or  gravel. 

I  have  had  under  my  care  a  young  married  woman  who 
has  suffered  from  abdominal  pains  for  two  years.  (See  Table 
I.,  No.  34.)  Up  till  a  few  months  before  I  saw  her  she 
had  been  treated  for  ovarian  inflammation,  but  whilst  under  a 
gynaecologist  of  repute  in  October  last,  calculus  in  the  left 
kidney  was  diagnosed.  If  correctly  reported,  this  gentleman 
was  of  opinion  that  an  operation  for  its  extraction  was  very 
dangerous  in  her  particular  case.  When  she  came  to  me 
there  was  almost  continuous  pain  in  the  left  renal  region, 
with  frequent  and  severe  attacks  of  renal  colic.  During  the 
attacks  a  swelling  formed  in  the  left  side  of  the  abdomen, 
and  no  urine  whatever  was  excreted.  Of  late  the  attacks 
had  lasted  three  da}Ts,  and  recurred  two  or  three  times  in 
a  fortnight.  On  examination,  the  right  kidney  was  felt  to 
be  very  hard  and  rather  larger  than  normal,  and  stones 
could  be  made  by  manipulation  to  grate  upon  one  another 
within  it.  I  believe  the  right  kidney  to  be  quite  useless, 
yet  she  has  never  felt  any  pain  in  it,  nor  had  occasion  to 
think  it  is  the  bed  of  a  large  stone.  This  case  illustrates 
two  points :  (1)  the  transference,  for  a  long  time,  of  pain 
to  the  ovary  from  the  left  kidney ;  (2)  the  absence  of  any 
symptoms  whatever  referred  to  the  right  kidney,  though 
stones  within  it  could  be  felt  through  the  abdominal  walls. 

Abscess  of  traumatic  origin,  or  stone  in  the  kidney,  may 
give  rise  to  symptoms  which  are  erroneously  ascribed  to  mis- 
placed or  deflected  uterus.  I  have  erased  parts  of  the  kidney 
of  a  lady  of  thirty  years  of  age  for  two  small  abscesses  of 
p 


66  HUNTERIAN  LECTURES. 

traumatic  origin,  in  each  of  which  there  was  a  calculous  mass. 
Yet  this  patient  had  been  treated  since  her  twenty-second 
year  for  misplaced  uterus,  and  had  worn  pessaries  during 
that  time.  There  was,  however,  no  real  abatement  of  her 
symptoms  till  after  the  operation  on  her  kidney. 

C.  Unsuspected  calculi  with  high  temperature  and 
great  psychical  disturbance. 

This  third  group  of  cases  is  well  illustrated  by  the 
following,  the  patient  being  desperately  ill  for  two  or  three 
months  with  symptoms  of  a  typhoid  type,  attended  with 
acute  but  vague  pains  over  the  whole  body,  and  with  great 
mental  prostration  ;  the  illness  terminating  after  the  discharge, 
presumably  from  the  left  kidney,  of  a  few  ounces  of  pus  and 
some  renal  calculi. 

On  June  16th,  1893,  I  saw,  with  Dr.  Ewart  of  Eastbourne, 
a  Mr.  C.  from  Alexandria,  where  he  occupied  a  position 
requiring  great  mental  and  bodily  activity.  For  a  few  days 
before  sailing  for  Europe  he  was  not  feeling  well,  and  on 
his  arrival  at  Brindisi  he  was  so  ill  and  in  such  pain  when 
moved  that  he  was  screaming  the  while  he  was  carried  ashore. 

With  great  difficulty  and  several  halts  he  reached  Aix, 
where  he  became  too  ill  to  go  further.  His  symptoms  whilst 
at  Aix  were  high  fever,  frequent  rigors,  and,  as  he  himself 
described  them,  excruciating  pains  all  over  him.  Sometimes 
the  pains  were  worse  at  one  part,  sometimes  at  another,  but 
there  was  a  slightly  marked  predominance  on  the  left  side  of 
his  trunk  and  left  lower  limb.  His  urine  was  turbid,  alkaline, 
and  offensive,  and  contained  pus.  It  was  suggested  that  he 
might  have  a  renal  calculus,  but  there  was  no  indication  in 
which  kidney  it  was. 

Accompanied  by  Dr.  Ewart  he  at  length  reached  London, 
though  once  or  twice  during  the  journey  it  seemed  impossible 
he  could  do  so  alive.  Frequent  doses  of  morphia  had  to  be 
given  to  relieve  pain. 

When  I  saw  him  on  his  arrival  in  London  he  was  emaciated 
to  a  marked  degree,  was  hectic,  and  had  a  high  temperature 
with  extreme,  general  rrypenesthesia. 

He  was  tender,  and  complained  of  pains  all  over  him ; 
cried  out  or  groaned  when  touched ;  but  at  one  time  he  would 
complain  most  bitterly  of  a  part  which  at  another  time  seemed 


"  UNSUSPECTED    RENAL   CALCULUS:'  67 

free  of  pain,  and  could  be  handled  without  hurting  him.  He 
was  shockingly  depressed,  would  take  no  food  willingly,  and 
lay  always  in  a  lethargic  state,  except  when  touched  or  moved, 
which  he  often  tearfully  resented.  By  his  relatives  he  was  seen 
to  be  quite  changed,  his  temperament  altered,  his  nerve  and 
moral  courage  lost.  He  was  a  different  man,  they  said.  The 
urine  was  1015,  turbid,  alkaline,  very  offensive,  depositing  an 
abundant  whitish  sediment,  and  contained  a  distinct  but  not 
a  large  amount  of  pus,  many  of  the  pus  cells  undergoing  fatty 
degeneration.  There  were  neither  blood  corpuscles,  sugar,  tube 
casts,  nor  tubercle  bacilli  in  the  urine.  On  the  folio  whig  day  I 
examined  him  under  an  anaesthetic.  Nothing  abnormal  was 
detected  about  his  bladder,  prostate,  or  urethra,  nor  in  any 
part  of  the  pelvis  or  abdomen.  There  was  no  undue  fulness 
or  hardness  of  either  kidney  to  be  felt. 

Drs.  Cayley  and  Ringer  saw  him  on  three  or  four  occasions 
with  me,  but  we  were  unable  to  come  to  any  definite  diagnosis 
except  that  there  was  some  focus  of  suppuration  somewhere 
within  range  of  the  genito-urinary  organs,  but  precisely  where 
we  were  unable  to  say.  On  the  whole,  it  seemed  most  likely  to 
be  in  the  left  kidney ;  but  with  this  uncertainty,  and  in  the 
serious  febrile  and  exhausted  state  of  the  patient,  I  was 
unwilling  to  urge  an  operation,  which  the  physicians  by  no 
means  encouraged  either.  He  improved  but  little  during 
his  stay  in  London,  and  on  July  15th  he  was  removed  to  his 
house  at  Eastbourne. 

On  September  18th  and  23rd,  1893,  Dr.  Ewart  wrote :  "  C. 
had  been  going  on  much  as  before,  always  high  temperature 
during  some  part  of  the  day,  pulse  bad,  feet  swelled,  and  I  did 
not  like  the  look  of  him  ;  the  urine  became  quite  sweet  (but 
always  alkaline  or  neutral)  under  the  use  of  carbolic  acid. 
Some  three  weeks  ago "  (i.e.  about  August  28th)  "  the  tem- 
perature went  to  103°  F.  after  a  severe  rigor,  and  kept  about 
the  same  for  fifty-eight  hours.  He  then  passed  six  ounces  of 
urine  and  one  ounce  and  a  half  of  pus,  and  two  days  after- 
wards he  passed  a  good-sized  stone.  Since  then  he  has  done 
well ;  but  even  now  there  is  an  indication  of  the  temperature 
going  up  again.  I  cannot  help  feeling  pretty  sure  there  is 
mischief  going  on  in  the  kidney  still.  He  eats  well  now  and 
goes  out  daily.     I  never  found  any  swelling  of  either  kidney, 


68  HUNTERIAN  LECTURES. 

but  I  have  no  doubt  the  left  is  the  one  affected.  Personally,  I 
think  the  man's  hysterical  condition  masked  his  real  symp- 
toms to  a  great  extent.  His  temperature  has  never  been  over 
99°  since  he  passed  the  stone  and  the  pus  in  the  urine  a 
month  ago.  He  has  put  on  ten  and  a  half  pounds  in  weight 
since  then."  On  Sunday,  October  8th,  1893,  Dr.  Ewart  wrote: 
"  On  Friday  (October  6th)  C.  passed  a  good  deal  more  pus,  and 
yesterday  four  little  stones  came  away  without  an}^  particular 
pain.  C.  himself  is  gaining  flesh  and  doing  well,  and  sails 
on  the  20th  for  Alexandria.  His  temperature  is  normal ;  his 
urine  contains  albumen  ;  he  passes  sixty  ounces  a  day.  Perhaps 
he  ought  to  have  an  exploration  made,  but  I  can't  help  think- 
ing a  ureter  which  has  been  sufficiently  dilated  to  be  travelled 
by  the  large  stone  is  a  very  effective  drain  to  the  kidney." 

He  returned  to  his  duties  in  Alexandria  on  October  20th, 
1893.  He  quite  recovered,  and  was  seen  by  Dr.  Ewart  in 
August  last  (1897)  in  excellent  health,  and  quite  his  natural 
self. 

A  very  similar  but  not  so  extreme  a  condition  of  high  tem- 
perature and  mental  disturbance  occurred  in  the  case  above 
quoted  (Table  I,  No  22)  ;  also  in  the  woman  whose  case 
is  No.  14  in  Table  VII.  This  latter  patient  had  had  a  calculus 
removed  from  the  left  kidney  before  she  came  under  me.  I 
removed  a  cyst  and  a  tuberculous  abscess  from  her  right 
kidney,  and  in  the  following  year  closed  the  fistula  remaining 
in  the  left  loin  after  the  stone  operation.  On  both  occasions, 
but  especially  the  last,  her  nervous  anxiety,  depression,  and 
terror,  and  the  high  temperature  were  very  marked  symptoms. 

The  same  phenomena,  it  is  true,  mark  other  kidney 
affections.  I  have  had  a  very  striking  proof  of  this  in  a  lady 
(Table  IV.,  No.  23)  whose  kidney  I  explored  for  calculus,  but 
the  condition  found  was  an  extensive  subcapsular  hemorrhage 
caused  apparently  by  a  strain.  This  patient's  illness,  like  Mrs. 
B.'s  and  Mr.  C.'s,  the  two  cases  related  above,  was  ushered  in 
with  fever,  and  quickly  followed  by  the  psj'-chical  symptoms  ; 
so  that  the  operation  had  nothing  to  do  in  causing  it.  Mrs.  B. 
improved  rapid]}7  after  the  operation.  Mr.  C.  was  not  operated 
upon  ;  but  this  lady  with  the  subcapsular  haemorrhage  became 
temporarily  worse  after  the  operation,  and  for  a  short  time 
was  melancholic  and  mentally  quite  deranged. 


"  UNSUSPECTED    RENAL    CALCULUS."  69 

There  are  a  few  other  cases  in  which  I  have  witnessed 
marked  nervous  symptoms  without  high  fever.  In  No.  21, 
Table  II.,  the  patient  was  quite  melancholic,  and,  according 
to  his  sister's  account,  had  become  so  depressed  mentally, 
and  so  inert  physically,  that  his  relatives  thought  his  nature 
had  entirely  changed.  The  night  before  his  operation  he 
spoke  to  strangers  in  the  surgical  home  in  which  he  was, 
of  the  certainty  he  felt  that  he  would  not  recover.  The 
operation  went  uneventfully,  but  when  he  came  out  of  the 
anaesthetic,  he  was  hemiplegic  and  aphasia  He  died  on  the 
second  day  after  the  operation,  and  at  the  post-mortem 
examination  thrombi  were  found  in  his  cerebral  vessels. 

In  my  only  fatal  nephrolithotomy  there  was  for  many 
hours  before  the  patient's  death  great  restlessness  with  mental 
depression  and  agitation.  And  in  a  case  (Table  III.,  No.  3) 
in  which  I  removed  a  kidney  atrophied  by  obstruction  from 
a  stone  impacted  in  the  lower  eud  of  the  ureter,  the  man's 
nervous  anxiety  and  alarm  were  prominent  features  through- 
out, at  any  rate  after  his  admission  to  the  hospital. 

It  is  a  question  whether  the  nervous  and  mental 
phenomena  without  fever  are  a  peculiar  form  of  ursemic 
brain  symptoms  ;  or  whether  the  renal  disease,  like  any 
other  serious  disease,  is  a  direct  cause  of  the  psychical  dis- 
turbance. The  character  of  the  disturbance  is  especially 
one  of  depression ;  melancholia,  stupor,  and  nervous  appre- 
hension of  danger  being  the  most  frequent  forms. 

Psychical  disturbance  has  been  often  noted  in  Bright's  and 
other  renal  diseases.  I  have  seen  it  in  advanced  lardaceous 
disease,  without  any  other  affection,  of  the  kidney.  But  in 
these  disorders  other  unmistakable  ursemic  symptoms  existed 
which  have  not  been  present  in  the  calculous  cases  to  which 
I  am  now  alluding. 

Another  question  is  :  why  are  these  psychical  disturbances 
in  some  cases  associated  with  fever  and  in  others  not  ?  Is  it 
the  result  of  some  molecular  transformation — excited  by  the 
local  irritation — upon  which  the  evolution  of  heat  depends ; 
or  is  it  due  to  some  special  form  of  bacterial  toxines  ? 

Are  there  special  micro-organisms  which  have  a  peculiarly 
disturbing  and  depressing  effect  upon  the  cerebro-spinal 
centres,  and  which   find  a   suitable   nidus   in  certain   states 


70  EUNTERIAN    LECTURES. 

of  the  kidney  or  urine  ?  Or  are  the  ordinary  pyogenic  bacteria 
under  certain  circumstances  so  influenced  by  direct  contact 
with  the  urine  in  the  kidney  as  to  become  the  cause  of  this 
psychosis  ?  It  can  hardly  be  the  latter,  because  one  sees  a 
greater  degree  of  suppuration  within  the  kidney,  with  the 
temperature  as  high  and  the  temperaments  of  the  patients 
much  the  same,  but  without  the  psychical  disturbances  to 
Avhich  I  refer. 

Nor  can  this  disturbance  be  referred  to  urasmic  poisoning. 
It  occurs  when  there  is  no  suppression  of  urine;  and  is 
absent  in  calculous  anuria  when  no  urine  is  secreted  for  six 
or  eight  or  more  days  in  succession.  The  temperature  is 
low,  not  high,  in  uraemia.  In  one  of  the  two  cases  (Mrs.  B.) 
the  temperature  fell  and  the  psychical  disturbance  ceased 
after  removing  a  calculus  from  the  non-suppurating,  not 
from  the  suppurating  kidney  ;  in  the  other  (Mr.  C.)  the 
symptoms  passed  after  the  discharge  of  some  pus  and  a 
few  calculi  with  the  urine. 

Perhaps  light  may  be  thrown  on  these  questions  by 
culture  experiments  with  the  urine,  and  especially  with 
that  removed  direct  from  the  affected  organ. 

QUIESCENT   CALCULUS. 

Quiescent  calculus  is  little  less  dangerous  to  its  possessor 
than  the  unsuspected  stone.  It  is  often  said,  "  The  stone  may 
settle  down  and  become  imbedded  in  the  kidney :  or  it  may 
pass  naturally,  and  then  there  will  be  no  further  trouble."  But 
often  this  is  not  so.  One  of  my  objects  in  this  lecture  is  to 
show  that  neither  the  one  nor  the  other  of  these  events  can  be 
looked  forward  to  with  perfect  equanimity ;  and  that  in  every 
case  in  which  a  stone  is  believed,  or  known,  to  be  present  the 
best  course  is  to  explore  the  kidney  and  remove  the  stone. 

We  ought  not  to  close  our  eyes  to  the  possibility  of  sudden 
danger  arising  from  a  hitherto  quiescent  calculus,  or  from  one 
giving  only  slight  and  occasional  reminders  of  its  existence. 
If  I  am  rightly  informed,  the  insurance  offices  are  wise  enough 
not  to  do  so ;  nor  should  the  surgeon. 

Several  cases  might  be  quoted  of  calculi  quiescent  for 
years  giving  trouble  at  intervals,  and  ultimately  causing 
serious   or  fatal   illness.      I    will   refer   briefly  to  two  cases. 


QUIESCENT   RENAL    CALCULUS .  71 

In  November,  1894,  I  saw  a  captain  in  the  merchant 
marine  service,  aged  forty- eight  (Table  III.,  No.  11).  He 
had  hematuria  first  when  a  boy  of  twelve  years  old.  For 
sixteen  years,  during  which  he  was  following  an  active 
seafaring  life,  he  seems  to  have  had  no  return  of  this 
symptom.  In  1874  he  fell  down  a  ship's  hold,  and  was  sup- 
posed to  have  injured  his  kidney.  Subsequently  he  had 
attacks,  at  long  intervals,  of  pain  in  the  right  loin  and 
hsematuria,  lasting  a  day  or  two.  These  attacks  occurred  in 
1877,  1880,  1885,  and  1894.  Between  the  attacks  there  Avas 
no  pain,  and  very  slight,  if  any,  blood  in  his  urine  ;  and  he 
continued  to  follow  his  profession  till  June,  1894,  when  he 
retired.  In  July  of  this  same  year,  after  gardening  a  good 
deal,  and  otherwise  exerting  himself  in  an  unusual  way,  he 
began  to  suffer  from  liver  trouble,  and  in  August  was  slightly 
jaundiced ;  at  the  same  time,  he  complained  of  paroxysmal 
pain  in  the  right  lumbar  region,  without  hematuria,  but  with 
a  little  albuminuria  and  a  heavy  deposit  of  phosphates  from 
the  urine.  The  lumbar  pain  at  that  time  was  not  intense,  but 
the  right  kidney  was  enlarged,  and  tender  on  pressure.  In 
October  and  November  the  lumbar  pain  became  severe  and 
the  hematuria  copious  and  continuous.  No  pus  had  ever 
been  detected  in  the  urine. 

Still  a  man  of  fine  physique,  he  had,  however,  lost  nearly  a 
stone  since  the  illness  began.  His  complexion  was  very  sallow, 
his  face  expressive  of  pain,  his  respirations  very  shallow,  and 
he  complained  of  excessive  weakness  and  of  feeling  terribly 
ill.  There  was  an  enormous  hard  bossy  fixed  tumour  in  the 
right  hypochondrium  and  right  lumbar  and  inguinal  regions, 
extending  high  up  beneath  the  ribs,  inwards  to  the  linea 
alba,  and  downwards  to  the  iliac  fossa.  The  loin  was  not 
prominent ;  there  was  resonance  in  front,  but  only  on  the 
inner  side  of  a  line  from  the  anterior  border  of  the  axilla. 
There  was  no  demarcation  between  the  tumour  and  the  liver 
dulness  ;  there  was  no  oedema  or  varicocele. 

The  tumour,  by  two  physicians  who  had  been  consulted, 
was  considered  to  be  a  hepatic  growth  ;  and  one  of  these  phy- 
sicians had  no  doubt  that  it  was  malignant  disease  of  the  liver. 

I  explored  through  the  linea  semilunaris,  and  ascertained 
that  there  was  no  growth,  and  that  the  liver  was  normal  but 


72  HUNTEBIAN  LECTURES. 

pushed  far  up,  and  that  the  swelling  was  entirely  renal.  I  at 
once  exposed  the  kidney  through  the  right  loin,  and  removed 
calculous  masses  to  the  weight  of  ten  ounces  and  a  large 
quantity  of  broken  down  grumous-looking  blood.  As  the 
kidney  bled  freely  and  was  entirely  disorganised,  and  as, 
owing  to  its  expanded  size,  and  the  tough,  fibrous  consistence 
of  the  renal  tissue,  it  was  very  difficult  to  stop  the  bleeding 
by  pressure,  I  rapidly  clamped  and  then  ligatured  the 
vessels  of  the  pedicle  and  removed  the  kidney.  The  kidney 
was  nine  inches  in  length  and  very  much  sacculated  at  each 
pole,  as  well  as  at  the  centre.  These  pouches  had  to  be 
emptied  of  their  contents — -which  consisted  of  old  blood  clot, 
and  gritty  sandy  calculous  matter — before  the  kidney  could 
be  removed  from  the  body. 

The  displacement  of  this  enormous  mass,  coupled  with  the 
deplorable  condition  of  the  patient  before  the  operation, 
brought  on  collapse.  Transfusion  was  performed,  and  for  a 
little  time  he  rallied  and  spoke;  but  he  soon  relapsed,  and 
died  within  three  hours  from  the  operation,  which  occupied 
an  hour  and  a  half. 

Here  we  have  an  unrivalled  instance  of  the  insidious 
course  of  calculus,  and  of  the  harm  it  works  even  when 
quiescent.  There  is  no  doubt  the  commencement  of  his 
calculous  life  dates  from  his  twelfth  year ;  yet  this  man 
goes  for  sixteen  years  without  symptoms — at  any  rate,  of 
sufficient  importance  to  attract  his  notice  or  fix  themselves 
in  his  memory ;  then,  after  an  injury,  symptoms  began  to 
show  themselves,  and  recurred  at  very  Jong  intervals  over 
a  period  of  twenty  years,  during  the  whole  of  which  time 
he  was  following  one  of  the  most  arduous  of  lives.  The 
calculus  all  this  while  was  insidiously,  unobtrusively  gather- 
ing force  ;  then  in  the  meridian  of  his  life,  and  just  as 
he  was  able  to  retire  from  his  profession,  his  latent  enemy 
broke  into  open  assault  and  caused  his  death  within  four, 
months. 

In  February,  1896,  I  saw  a  patient  in  his  forty-fifth  year 
(Table  II.,  No.  32)  who  gave  the  following  history.  "  In  1865, 
when  thirteen  and  a  half  years  old,  I  received  a  kick  over 
the  left  lower  ribs,  and  the  lowest  two  were  broken.  In  1877 
I  noticed  a  little    blood    in  the  urine,  and  following  this  a 


QUIESCENT   RENAL    CALCULUS.  73 

creamy  deposit.  In  1879  I  had  a  short,  sharp  attack  of 
severe  pain,  lasting  twenty-four  to  thirty  hours,  in  the  left 
side,  with  great  shivering  and  sweating  afterwards. 

"At  irregular  intervals,  up  to  1891,  I  had  attacks  of  pain 
in  the  left  side,  with  rigors  and  sweating,  followed  by  an 
immense  quantity  of  pus  in  the  urine.  During  this  period 
I  was  on  service  in  the  Mediterranean,  the  Red  Sea,  and 
Australia.  There  was  some  pus  always  present  in  the  urine, 
except  just  previous  to  a  rigor,  when  the  urine  would  become 
clear,  and  remain  so  till  the  sweating  set  in,  when  a  lot  of  pus 
came  away,  and  I  got  better.  The  whole  attack  would  be  over 
in  twenty-four  hours,  or  less.  The  attacks  were  often  induced 
by  hunting.  In  December,  1889,  I  got  a  fall  from  my  horse, 
and  after  this  had  very  marked  hseinaturia  for  ten  days.  A 
physician  in  London  who  now  saw  me  diagnosed  a  renal 
calculus,  but  said  that  an  operation  for  its  removal  was  out 
of  the  question.  Previously  I  had  seen  some  of  the  best 
surgeons  in  London,  who  had  told  me  I  had  nothing  the 
matter  with  my  kidneys,  but  attributed  my  symptoms  some 
to  the  bladder,  others  to  the  prostate.  Since  November.  1890, 
with  more  careful  dieting,  and  being  almost  a  total  abstainer, 
I  had  only  had  two  or  three  slight  attacks  up  to  the  time 
you  first  saw  me  in  February,  1896,  and  I  was  able 
to  lie  upon  my  left  side,  which  I  had  not  been  able  to  do 
previously." 

He  thought  nothing  of  walking  twenty  miles  when  in  Africa 
in  1895,  and  he  had  had  over  five  years  of  almost  complete 
abeyance  of  symptoms,  when,  on  February  13th,  1896,  whilst 
hunting  on  a  very  restive  horse,  he  felt  something  give  way 
in  the  left  kidney,  and  during  the  succeeding  four  days  the 
kidney  "kept  filling,"  becoming  more  tender  and  painful, 
until  he  could  neither  walk,  nor  sit,  nor  lie  down  except  in 
a  coiled-up  posture,  and  even  so  he  was  in  great  pain. 
There  was  at  this  time  a  tumour  reaching  to  the  linea 
semilunaris  (left),  extending  high  up  beneath  the  costal 
margins  and  downwards  below  the  crest  of  the  ilium. 
Pulse  regular,  76.  Temperature  normal.  Urine  was  1012, 
acid  and  contained  albumen.  The  diagnosis  was  "  left 
kidney  blocked,  opposite  kidney  working  actively  and 
healthily." 


74  HUNTERIAN  LECTURES. 

On  February  21st  I  opened  his  left  kidney  through  the 
loin  and  let  out  a  large  quantity  of  fluid  blood  and  blood  clot 
A  calculus  weighing  260  grs.,  tightly  impacted  in  the  renal 
pelvis,  was  extracted  through  the  incision  in  the  convex  border 
of  the  kidney.  The  kidney  was  converted  into  an  exten- 
sively sacculated  cavity,  with  a  very  thin  wall,  in  places  not 
thicker  than  a  penny-piece.  This  shell  of  a  kidney  was  not 
removed,  because  it  was  so  adherent  to  surrounding  parts 
and  reached  so  high  up  beneath  the  diaphragm.  The  wound 
healed  rapidly,  and  he  left  London  for  his  home  (on  March 
16th)  twenty- two  days  after  the  operation,  with  a  small  sinus, 
which  to  my  surprise  healed  a  fortnight  later. 

All  continued  well,  and  he  was  "  better  than  he  had  been 
for  twenty  years,"  when,  on  April  24th,  in  spite  of  cautions 
against  riding  and  other  exercises — till  the  kidney  had  had 
time  to  contract — he  took  part  in  the  practice  of  a  torpedo- 
destroyer  from  ten  till  one  o'clock  one  day,  the  vessel  travelling 
thirty  knots  an  hour,  and  he  subjected  to  the  vibration,  which 
was,  of  course,  continuous  and  considerable.  At  two  p.m.  he 
felt  chilly,  his  kidney  swelled  and  became  painful ;  feverishness 
and  an  evening  temperature  of  101°  followed ;  and  on  April 
30th,  and  again  on  M&y  2nd,  the  cicatrix  yielded,  and  a 
large  quantity  of  blood  escaped  on  each  occasion.  A  short 
pus-secreting  fistula  followed,  and  has  continued  up  to  the 
present ;  but  he  has  long  since  been  leading  a  very  active 
life  in  command  of  one  of  H.M.'s  ships,  and  declares  himself 
in  better  health  than  ever. 

I  have  a  pile  of  letters  and  prescriptions  from  several 
eminent  physicians  and  surgeons  written  to  this  patient  be- 
tween 1880  and  1891.  They  have  been  to  me  interesting  read- 
ins:  ;  for,  though  honour  is  due  to  the  writers  of  such  careful  and 
candid  opinions,  they  evince  the  most  absolute  want  of  con- 
fidence in  the  efficacy  and  safety  of  the  surgical  treatment 
of  stone ;  and  its  trial  in  this  particular  case  was  distinctly 
discountenanced.  But  how  much  better  for  the  patient  if 
the  stone  had  been  removed  in  1880,  before  the  kidney  had 
been  destroyed !  He  would  thereby  have  been  spared  a 
very  severe  illness,  which  made  an  operation  imperative, 
after  all,  in  order  to  save  his  life ;  but  was  performed  too 
late  to  save  his  kidney. 


MIGRATORY   RENAL    CALCULUS.  75 

MIGRATORY    CALCULI. 

Lastly,  I  Avant  to  show  the  possible  and  actual  dangers 
of  leaving  a  calculus  to  make  its  own  way  out  of  the  urinary 
passages. 

And  in  this  connection  let  me  ask  what  would  be  thought 
of  a  surgeon  who  advised  a  patient  with  stone  in  his  bladder 
to  wait  a  few  months  and  see  if  it  would  pass  through  the 
urethra  naturally  and  unassisted,  on  the  ground  that  it  was 
only  a  little  stone,  and  therefore  would  be  able  to  make  its  way 
perhaps  without,  perhaps  by  dint  of,  stretching ;  that  the  pro- 
cess might  be  a  very  painful  one,  or  might  not ;  that  when 
once  the  calculus  got  into  the  passage  the  force  of  the  pressure 
of  urine  behind  would  be  almost  sure  to  drive  it  onwards,  but 
that  if  it  did  not  do  so,  or  alarming  symptoms  arose  due  either 
to  the  over-distension  of  the  organs  behind,  or  to  the  sloughing 
of  the  part  of  the  tube  in  which  the  calculus  was  impacted, 
then  and  then  only  resort  should  be  had  to  an  operation. 

Well,  this  is  precisely  the  line  of  argument  daily  acted 
upon  in  the  case  of  renal  calculus.  And  why  ?  Not  because 
less  damage  to  the  kidney  will  result  from  the  obstruction  in 
the  ureter :  on  the  contrary,  the  serious  effect  of  a  blocked 
ureter  is  much  earlier  and  much  more  rapid  in  its  progress ; 
not  because  the  suffering  from  renal  calculus  is  less  than  from 
vesical  calculus ;  not  because  extravasation  of  urine  never 
occurs  from  obstructed  ureter  or  renal  pelvis,  for  witness  the 
perinephric  and  periureteral  abscesses  and  fistulee  :  but  because 
of  the  supposed  risks  to  life  of  operation  on  the  kidney.  But 
this  reason  is  really  no  longer  tenable.  No  operation  practised 
for  vesical  calculus  has  a  lower  mortality  than  nephrolithotomy, 
i.e.  excision  of  a  calculus  from  an  otherwise  healthy  kidney. 
Nephrolithotomy  is,  when  properly  performed,  no  less  free 
from  after  ill  effects  than  lithotrity. 

I  have  not  been  blameless  in  this  respect.  On  the  contrary, 
for  years  I  made  it  a  practice  in  cases  in  which  the  symptoms 
were  slight,  and  of  only  recent  occurrence,  to  treat  the  patients 
for  a  time  on  the  expectant  plan.  I  have  advised  many  in 
this  manner,  and  have  often  been  gratified  to  hear  of  the 
subsequent  successful  passage  of  the  stone.  I  have  several 
specimens  of  this  sort  in  my  cabinet,  but  I  am  no  longer 
proud  of  them ;  they  are  the  emblems  of  what  ought  to  be 


76  HUNTERIAN  LECTURES. 

very  largely  an  obsolete  treatment,  and  from  which  I  have 
had  one  or  two  rude  awakenings. 

A  patient,  thirty-three  years  of  age,  had  very  slight  symp- 
toms of  renal  calculus ;  namely,  occasional  slight  pain  about 
the  upper  part  of  the  left  ureter  rather  than  the  kidney, 
and  passage  of  urine,  which,  often  as  I  examined  it,  was 
neutral,  phosphatic,  and  microscopically  showed  blood  and  pus 
cells  and  small  crystals  of  calcium  oxalate.  His  custom  was 
to  come  to  England  for  the  summer  months  and  play  cricket 
for  his  native  county,  and  to  pass  the  rest  of  the  year  in 
Queensland,  where  he  had  a  large  farm.  During  the  summers 
of  1894  and  1895  (when  he  was  consulting  me)  he  played 
cricket  and  tennis  regularly,  in  spite  of  occasional  mild  attacks 
of  ureteral  pain ;  and  was  quite  unwilling  to  submit  to  any 
operation.  Towards  the  end  of  the  season  of  1895  he  married, 
and  on  the  third  day  of  his  honeymoon,  and  a  week  or  two 
before  sailing  for  Queensland,  he  came  to  me  in  great  agony, 
and  unable  to  pass  urine,  in  spite  of  frequent  straining,  due  to 
a  calculus  impacted  in  the  prostatic  urethra. 

It  was,  of  course,  quite  easy  to  push  the  stone  back  at  once 
into  the  bladder,  draw  off  the  urine,  and  later  in  the  day 
perform  lithotrity.  In  two  or  three  days  he  was  just  as  if 
nothing  of  the  kind  had  happened,  and  was  relieved  of  his 
calculus  into  the  bargain. 

But  what  would  have  become  of  this  newly  made  husband 
had  the  same  accident  happened  a  few  weeks  later  when, 
instead  of  being  within  a  mile  of  a  hundred  able  surgeons,  he 
had  been  out  in  the  bush  without  a  doctor  of  any  kind  within 
two  or  three  hundred  miles  of  him  ;  or  if  instead  of  the  calculus 
lododno-  near  the  vesical  orifice  of  the  urethra,  it  had  blocked 
the  ureter  where  it  crosses  the  brim  of  the  pelvis,  and  this  had 
occurred  just  afterjleaving  port  for  a  three  or  four  weeks'  sail  ? 
Either  of  these  contingencies  might  have  happened  in  his  case. 

This  leads  me  to  mention  what  did  happen,  in  another 
case,  from  a  stone  blocking  a  ureter  at  this  spot. 

A  man  aged  thirty-two,  about  two  months  after  feeling 
pain  in  the  right  loin,  had  an  attack  of  renal  colic.  The  pain 
was  very  severe,  lasted  four  hours,  and  was  accompanied  with 
retraction  of  the  right  testis,  and  haeinaturia.  This  occurred 
three  weeks  before  I  saw  him. 


MIGRATORY   RENAL    CALCULUS.  77 

After  the  attack,  carriage  or  horse  exercise,  and  any 
extra  exertion,  brought  on  severe  pain  in  his  right  loin, 
accompanied  by  hematuria.  His  urine  was  1010,  and 
contained  albumen.  I  advised  him  to  go  home  and  rest 
for  a  month,  and  if  the  pain  continued,  or  the  colic 
recurred,  to  have  an  operation.  He  did  not  rest  long; 
but  a  week  after  rode  on  horseback,  and  carried  a  heavy  bag 
along  a  station  platform.  Then  he  was  seized  with  the  most 
violent  pain  in  the  course  of  the  ureter,  where  it  crosses  the 
pelvic  brim,  and  a  hard  body,  like  a  stone,  could  be  felt 
there  through  the  abdominal  walls.  After  ten  days  of  the 
most  frightful  suffering,  during  all  which  time  the  calculus 
could  be  felt  in  the  same  position,  the  patient  declared  he 
could  bear  his  sufferings  no  longer.  He  made  a  long  railway 
journey  to  London,  and  was  operated  by  a  London  hospital 
surgeon.  Cceliotomy  in  the  median  line  was  performed,  and 
through  this  a  small  rough  stone  in  the  ureter  was  steadied 
between  the  linger  and  thumb  of  an  assistant,  whilst  the  sur- 
geon performed  retroperitoneal  ureterotomy  through  a  slightly 
oblique  wound  in  the  right  ilio-costal  space  and  extracted  the 
calculus.  What  occurred  afterwards  was,  I  believe,  this :  both 
parietal  wounds  healed  well,  and  an  urinary  fistula  in  the  right 
loin  showed  signs  of  closing,  when  urine  was  extravasated  into 
the  pelvis  tissues  through  the  ureteral  wound.  No  doubt  the 
wall  of  the  ureter  where  the  stone  had  lodged  was  thinned 
and  contused  by  the  ten  days'  impaction  of  the  rough-surfaced 
calculus,  and  so  repair  did  not  proceed  in  it  after  the  calculus 
was  removed. 

This  extravasation  was  followed  by  suppuration  and  by 
the  discharge  of  pus  per  rectum  and  by  symptoms  of  obstruc- 
tion of  the  left  kidney,  owing  to  pressure  upon  the  ureter 
by  the  inflamed  pelvic  cellular  tissue.  The  left  kidney  was 
explored,  and  found  to  be  greatly  congested.  No  stone,  only 
a  few  particles  of  gritty  material,  were  found  in  it.  A  month 
or  so  later,  when  all  seemed  going  well,  a  repetition  of  the 
symptoms  in  the  left  kidney  took  place,  and  a  great  extra- 
vasation of  urine,  requiring  a  large  incision  in  the  right  iliac 
region,  occurred. 

A  week  later,  as  he  was  not  making  satisfactory  progress, 
I  was  asked  to  see  him.     He  had  undergone  three  operations, 


78  HUNTERIAN  LECTURES. 

and  now  had  four  long  scars,  two  on  the  front  of  the  belly 
and  one  in  each  loin,  with  a  fistulous  track,  from  the  injured 
ureter,  opening  in  the  right  loin ;  and  there  was,  I  under- 
stood, another  laparotomy  contemplated,  but  this  I  hope  was 
not  done.  Here  was  a  case  of  a  professional  career  checked,  if 
not  permanently  ruined,  by  a  little  calculus  weighing  not  more 
than  two  or  three  grains.  A  long  convalescence  certainly 
was  before  him;  possibly,  later  on,  the  necessity  of  neph- 
rectomy for  a  permanent  fistula;  or  gradual  destruction 
of  the  kidney  from  stenosis  of  the  ureter  at  the  seat  of 
impaction  and  operation. 

Such  a  case,  even  if  but  one  in  a  thousand,  teaches  a  grave 
lesson  ;  and  my  reflections  upon  it,  and  upon  that  of  the 
colonist  above  quoted,  convince  me  that  the  expectant  treat- 
ment— excusable  because  inevitable  before  nephrolithotomy 
was  proved  to  be  the  safe  operation  it  is — is  no  longer 
justifiable. 

Summary. — The  conclusions  at  which  I  have  arrived  are 
the  following  : 

(1)  That  the  aim  of  the  surgical  treatment  of  renal 
calculus  should  be  to  extend  the  application  of  nephro- 
lithotomy, and  thereby  restrict  the  necessity  of  nephrotomy 
and  nephrectomy. 

(2)  That  more  frequently  than  not,  the  failure  to  find  a 
stone  is  not  in  reality  a  failure  of  treatment,  because  there 
are  so  many  curable  morbid  conditions  which  mimic  renal 
calculus,  and  which  are  discoverable  only  by  exploration. 

(3)  That  the  theory  that  a  stone  in  one  kidney,  whether 
that  kidney  is  itself  painful  or  not,  reflects  or  transmits 
pain  to  the  opposite  kidney,  is  quite  unproven ;  that  it  is  a 
dangerous  theory,  calculated  to  lead  to  very  erroneous  prac- 
tice ;  and  that  the  surgical^rinciple  with  regard  to  exploratory 
operation  should  be  that  with  pain,  paroxysmal  or  con- 
tinuous, on  one  side  only,  the  kidney  on  the  painful  side 
should  be  explored. 

(4)  That  nephrectomy  for  calculous  conditions  is  very 
rarely  called  for,  and  should  be  done  only  in  most  exceptional 
cases.  Nephrotomy  for  calculous  pyonephrosis  is  the  proper 
operation — at  any  rate  as  a  primary  operation — because  of  the 
frequency  of  double  calculous  disease.     Experience  has  shown 


RENAL    CALCULUS -CONCLUSIONS.  79 

that  kidneys  from  which  stones  weighing  830  grs.  and  1,300 
grs.  have  been  removed,  may  be  sufficient  to  maintain  life 
during  the  blocking  or  suspended  action  of  the  opposite  organ. 

(5)  That  nephrectomy  of  a  completely  disorganised  kidney, 
whilst  the  opposite  organ  is  occupied  by  calculus,  is  almost 
certainly  followed  by  death  ;  whereas  nephrectomy,  after  the 
opposite  kidney  has  been  freed  of  stone,  and  allowed  some 
time  to  recover,  will  probably  be  followed  by  recovery  from 
the  operation  and  possibly  by  very  good  health  subsequently. 

(6)  That  when  renal  calculus  causes  reflected  or  trans- 
ferred vesical  or  ovarian  pain  the  removal  of  the  calculus 
will  be  followed  by  complete  cure  of  the  bladder  or  ovarian 
symptoms. 

(7)  That  in  some  cases  renal  calculous  conditions  are 
attended  by  very  remarkable  nervous  symptoms,  sometimes 
with,  sometimes  without,  high  temperature,  and  that  informa- 
tion as  to  the  cause  of  these  symptoms  is  needed. 

(8)  That  unsuspected  renal  calculi  are  a  source  of  very 
real  danger  to  their  possessors ;  and  when,  whether  by 
accident  or  by  the  systematic  examination  of  the  urine,  we 
have  cause  to  suspect  the  presence  of  a  calculus,  Ave  should 
recommend  its  immediate  removal,  regardless  of  the  fact  that 
it  is  not  causing  renal  or  transferred  pain. 

(9)  That  quiescent  calculus  is  as  dangerous  to  the  indi- 
vidual as  unsuspected  calculus,  and  ought  to  be  removed  by 
operation. 

(10)  That  the  hitherto  accepted  teaching,  that  a  renal  cal- 
culus, if  causing  only  mild  symptoms,  even  though  extending 
over  a  lengthened  period ;  or  attacks  of  severe  colic  of  only 
recent  occurrence,  should  be  treated  on  the  expectant  plan, 
ought  to  be  discarded  as  unsound  in  theory  and  dangerous 
in  practice. 

(11)  That  the  same  principle  should  be  applied  to  renal 
calculus  which  has  long  been  the  rule  in  regard  to  vesical 
calculus,  namely,  when  suspected  it  should  be  searched  for, 
when  known  to  exist  removed,  without  waiting  in  the  hope 
that  it  may  become  encysted  or  spontaneously  expelled. 

(12)  That  the  very  low  mortality  of  nephrolithotomy 
puts  this  operation  upon  the  same  footing  for  renal  calculus  as 
lithotrity  in  the  most  experienced  hands  for  vesical  calculus. 


LECTUEE    III. 

FISTULA  CAUSED  BY  RENAL  CALCULUS;  OBSTRUC- 
TIVE ANURIA  DUE  TO  RENAL  CALCULUS;  THE 
TECHNIQUE  OF  THE  EXPLORATION  OF  THE 
KIDNEY  AND  URETER  FOR  CALCULUS. 

Mr.  President  and  Gentlemen, — In  the  second  lecture  I 
endeavoured  to  show  (1)  that  the  errors  and  uncertainties  in 
the  diagnosis  of  renal  calculus  had  in  many  instances  been  of 
distinct  advantage,  because  they  had  led  to  the  exploration  of 
the  kidney,  and  this  in  turn  to  the  discovery  and  cure  of 
various  morbid  conditions  other  than  those  due  to  stone. 
(2)  That  unsuspected,  quiescent,  and  migratory  renal  calculi 
cause  very  destructive  and'  even  fatal  consequences,  and  that 
we  ought  to  revise  our  practice  with  regard  to  the  early  treat- 
ment of  renal  calculus.  (3)  That  the  low  mortality  of  nephro- 
lithotomy (i.e.  the  operation  for  renal  calculus  in  its  early 
stages),  and  the  high  mortality  of  nephrotomy,  and  the  still 
higher  mortality  of  nephrectomy  (i.e.  of  the  operations  per- 
formed for  the  advanced  disorders  due  to  renal  calculus),  show 
the  advisability  of  operating  at  as  early  a  stage  as  possible. 

In  further  support  of  this  conclusion,  I  may  point  to 
Table  IV.,  the  exploratory  operations,  and  Table  V.,  the 
operations  for  movable  kidney.  There  are  forty-two  of  the 
former,  and  fifty-seven  of  the  latter,  with  only  one  death  which 
can  in  any  way  be  attributed  to  the  operation. 

It  will  be  seen  in  Table  IV.  that  three  cases  are  recorded 
as  deaths  (Nos.  15,  22,  and  25),  but  a, glance  at  the  abstracts 
shows  that  the  deaths  were  due  entirely  to  other  causes.  Two 
of  the  patients  lived  long  enough  to  absolutely  recover  from 
the  operations,  and  ought  to  be  counted  therefore  as  recoveries ; 
the  third  (No.  25)  died  from  obstinate  vomiting  and  hsema- 
temesis  from  a  gastric  ulcer  on  the  second  day  after  the 
operation,  and  therefore  ought  to  be  excluded. 

In  Table  V.  there  is  not  a  death  from  any  cause  whatever 
in  the  whole  number  (57)  of  operations  for  movable  kidney. 


SLIGHT  MORTALITY  OF  OPERATION.  81 

If  I  add  that  in  nearly  every  instance  the  kidneys  operated 
upon  were  brought  out  on  to  the  surface  of  the  loin,  and  in  a 
very  large  number  of  them  the  convex  border  of  the  kidney 
was  incised  and  sutured,  it  will  be  understood  that  these 
operations  from  the  point  of  view  of  risk  are  essentially  the 
same  as  neprolithotomy. 

When  the  cases  in  these  three  tables  are  added  together, 
excluding  the  one  referred  to  above,  we  get  the  following 
result : — 

Table     I. — 34  operations,  33  recoveries,  1  death. 
„     *IV. — 41  operations,  40  recoveries,  1  death. 
V. — 57  operations,  57  recoveries. 
Total — 132  operations,  130  recoveries,  1  death. 

Thus  out  of  a  total  of  132  operations,  the  essential  characters 
of  which  are  much  the  same,  there  were  130  recoveries  and 
2  deaths. 

At  the  Middlesex  Hospital,  where  renal  operations  are 
freely  undertaken  by  the  members  of  the  surgical  staff, 
a  good  many  persons  nevertheless  die  from  the  effects  of 
renal  calculus  who  are  too  ill  to  be  operated  upon  when  ad- 
mitted. During  the  years  1885  to  1895  inclusive,  calculi 
were  found  in  the  kidneys  in  45  out  of  3,331  post-mortem 
examinations,  and  hydronephrosis  due  to  calculus  impacted 
in  the  ureter  was  found  in  four  others.  That  is  in  one  and  a 
half  per  cent,  of  persons  dying  of  all  conceivable  causes,  calculi 
were  found  in  one  or  both  kidneys  or  ureters. 

Many  of  these  45  bodies  found  their  way  to  the  post- 
mortem room  entirely  because  of  calculous  disease  ;  and  in  the 
rest  renal  calculi  contributed  more  or  less  to  the  fatal  result. 
Amongst  the  45  cases  there  were  10  instances  of  suppuration 
in  one  or  both  kidneys;  11  cases  of  perinephric  abscess; 
four  cases  in  which  calculi  were  present  in  both  kidneys ; 
and  four  others  in  which  only  one  kidney  could  be  said  to 
exist,  the  other  having  undergone  complete  atrophy  due  to 
obliterated  ureters  in  three  of  them,  and  cystic  degeneration 
from  obstruction  in  the  fourth. 

*  In  Table  IV.,  No.  25  is  excluded  from  this   computation   for  obvious 
reasons  (see  Table). 

G 


82  HUNTERIAN  LECTURES. 

Besides  these  45  cases,  there  were  63  instances  of  suppura- 
tive nephritis,  in  most  of  which  both  kidneys  were  affected  ; 
and  in  many  of  them  renal  calculus  had  played  a  con- 
spicuous part. 

FISTULA. 

In  considering1  the  harmful  effects  of  renal  calculi,  whether 
unsuspected,  quiescent,  and  migratory  or  not,  it  is  impossible 
to  leave  out  of  account  renal  and  ureteral  fistula. 

A  fistula  may,  it  is  true,  occur  as  a  sequel  to  an  opera- 
tion on  the  kidney;  but  it  is  a  more  serious  matter  when 
it  is  a  result  of  perinephric  suppuration  where  no  operation 
has  been  done.  It  is  after  nephrotomy  for  calculous  pyo- 
nephrosis, especially,  that  a  fistula  due  to  operation  is  most 
likely  to  occur. 

It  is  exceptional  for  a  permanent  or  long-standing 
fistula  to  result  from  nephrolithotomy,  or  any  operation  for 
movable  kidney,  or  a  simple  exploration.  This  is  rather 
surprising  if  we  consider  the  nature  of  the  tissue  surrounding 
the  kidney,  its  proximity  to  the  colon,  the  fact  that  there 
is  often  an  escape  of  a  little  urine  when  the  kidney  is  in- 
cised, and  that  the  action  of  the  lower  ribs  and  abdominal 
muscles  in  the  immediate  neighbourhood  of  the  wound  is 
almost  incessant,  and  sometimes  violent,  as  in  coughing, 
retching,  and  straining  at  stool. 

Fistula  is  also  exceptionally  rare  after  nephrectomy, 
except  when  perinephritis  or  perinephric  abscess  has  pre- 
viously existed.  In  cases  of  nephrectomy  for  calculous 
disease,  perinephritis  has  usually  preceded  the  operation, 
but  in  spite  of  this,  a  fistula  followed  in  only  one  out  of 
twelve  of  my  surviving  nephrectomies  for  stone — i.e.  at  the 
rate  of  a  little  more  than  8  per  cent. — and  in  that  case  the 
fistula  was  superficial,  and  probably  healed  shortly  after  the 
patient  left  the  hospital,  though  I  have  no  certain  know- 
ledge that  it  did  so. 

Out  of  my  33  nephrolithotomies  which  survived,  a  super- 
ficial sinus  occurred  in  two  (Table  I.,  Nos.  1  and  9),  and  an 
urinary  sinus  in  two  (Table  I.,  Nos.  6  and  22).  In  the  two 
latter  very  large  incisions  involving  the  pelvis  of  the  kidney- 
had  to  be  made  for  the  extraction  of  stones  of  great  size. 


FISTULA   CAUSED  BY  RENAL   CALCULUS.  S3 

After  nephrotomy  for  advanced  calculous  conditions,  e.g. 
calculous  pyonephrosis,  fistulas  either  temporary  or  per- 
manent, occurred  in  37  5  per  cent,  of  the  cases  operated 
upon.  Though  in  many  of  these  the  fistulas  subsequently 
healed,  still  the  fact  that  even  a  temporary  fistula  followed  in 
so  large  a  proportion  of  cases  affords  a  further  argument  in 
favour  of  early  operation  for  stone  in  the  kidney. 

But  the  fistulas  which  occur  independently  of  any  oper- 
ation, which  are  due  in  other  words  to  long-retained 
renal  calculi,  should  appeal  even  more  strongly  to  surgeons 
as  an  argument  against  delaying  operative  treatment  for 
stone. 

The  persistency  of  these  fistulas,  the  recurrence  of  deep 
suppuration  if  the  external  orifice  of  the  fistula  is  allowed  to 
close,  together  with  the  abiding  troubles  caused  by  the 
continued  presence  of  the  stone  in  the  kidney  or  ureter, 
will  sooner  or  later  induce  the  patient  to  demand  surgical 
assistance. 

Then  the  patient  has  to  undergo  risks  and  the  surgeon 
to  face  difficulties  which  only  occur  when  the  perinephric 
structures  are  matted  and  hardened  by  long-standing  in- 
flammation or  suppuration;  and  have  become  so  densely 
adherent  to  the  kidney  capsule  that  it  is  often  no  easy 
matter  to  find  the  kidney. 

In  a  stout  person  with  a  deep  loin  it  may  be  quite  im- 
possible to  distinguish  the  kidney  at  all  by  touch ;  whilst  the 
resisting  nature  of  the  tissues,  and  the  depth  of  the  wound, 
make  it  impossible,  except  through  a  very  extensive  incision, 
and  perhaps  only  after  the  excision  of  the  last  rib,  to  bring 
the  kidney  within  sight. 

Another  and  very  important  fact  is  that  these  condensed 
contracted  tissues  fill  the  hilum  and  surround  the  whole 
of  the  kidney  with  a  fibro-lipomatous  mass,  which  shortens 
and  stiffens  the  pedicle,  and  compresses  and  destroys  the 
elasticity  of  the  renal  vessels  and  of  the  ureter.  The  result 
of  this  is  that  the  kidney  gets  tucked  close  up  against  the 
spinal  column,  and  as  firmly  set  in  its  surroundings  as  if 
it  were  imbedded  in  plaster  of  Paris.  If  nephrotomy  is  done 
under  these  conditions,  the  renal  artery  cannot  be  controlled 
when  the  renal  parenchyma  is  incised  and  the  kidney  cavity 


84  EUNTEEIAN  LECTURES. 

explored ;  and  thus  bleeding  is  apt  to  *be  very  free.  If 
nephrectomy  is  performed  the  risks  and  difficulties  in  dealing 
with  the  pedicle  are  enormously  increased. 

When  a  fistula  is  in  course  of  formation  the  perinephric 
abscess  should  be  opened  as  soon  as  possible,  lest  the  matter 
should  burrow  and  discharge  in  some  dangerous  direction. 
It  is  true  the  abscess  will  often  make  for  the  loin,  or  groin, 
and  open  spontaneously  on  the  surface,  if  it  be  not  incised ; 
but  it  should  not  be  suffered  to  do  so. 

If  on  opening  a  perinephric  abscess  a  calculus  presents, 
or  is  readily  detected  on  the  introduction  of  the  finger  into 
the  cavity,  it  should,  of  course,  be  removed.  Several  cases  of 
this  sort  are  on  record. 

It  is,  however,  as  a  rule,  unsafe  to  search  for  and  explore 
the  kidney  when  the  tissues  surrounding  it  are  in  an  acutely 
suppurating  condition.  The  safer  course  is  to  defer  the 
exploration  of  the  kidney  till  after  the  abscess  is  healed. 
This  necessitates  a  lengthy  convalescence,  followed  by  a 
fistula,  and  a  second  operation,  before  the  cause  of  the  abscess 
can  be  removed.  After  this  second  operation,  whether  it  be 
nephrotomy  or  nephrectomy,  it  is  not  unfrequent  for  the 
healing  of  the  wound  to  be  delayed  by  profuse  and  prolonged 
suppuration. 

The  same  drawbacks  attend  operations  for  calculous  affec- 
tions of  long  standing  if  perinephritis  without  abscess  or  fistula 
has  existed.  There  may  be  the  same  matting  of  the  tissues, 
the  same  fixation  of  the  kidney,  the  same  inelasticity  of  the 
pedicle,  the  same  ingrowth  of  fibro-lipomafeous  tissue  at  the 
hilum,  and  the  same  incompressibility  of  the  renal  vessels. 

If  perinephritis  has  commenced  before  nephrotomy  is 
performed  neither  the  extraction  of  a  calculus  nor  the  evacua- 
tion of  pus  from  the  renal  cavity  may  prevent  the  spreading 
of  the  inflammatory  process  in  the  surrounding  cellular 
tissue,  and  the  formation  of  a  fistula  at  a  long  distance  from 
the  kidney. 

A  good  illustration  of  this  is  afforded  by  a  male  patient 
(Table  II.,  No.  37),  from  whom,  in  February,  1897, 1  excised  the 
last  rib  in  order  to  remove  from  his  kidney  several  fragments 
of  calculus  which  were  assisting  to  keep  up  a  very  bad  fistula. 
Subsequently  I  had  to  excise  also  portions  of  the  ninth,  tenth, 


FISTUL.E  CAUSED  BY  RENAL   CALCULUS.  85 

and  eleventh  ribs  to  enable  this  long  fistulous  track  to  close. 
The  history  of  the  case  is  briefly  this :  an  abscess  formed  and 
was  opened  between  the  eighth  and  ninth  ribs,  three  weeks 
after  nephrotomy  by  another  surgeon  at  Christmas,  1895. 
At  this  first  operation  some  large  pieces  of  calculus  were 
extracted  from  the  kidney.  A  fistula  with  a  double  opening 
ultimately  followed  ;  one  aperture  being  where  the  abscess 
had  been  opened,  in  the  eighth  intercostal  space  behind ; 
and  the  other  aperture  in  the  iliocostal  space  in  the  scar 
of  the  operation  wound.  This  fistula  persisted  without 
interruption,  and  was  attended  by  great  debility  and  attacks 
of  high  fever  up  to  the  time  of  the  operation  in  February,  1897. 

In  a  case  reported  by  Mr.  Wright  a  fistula  in  the  groin 
followed  nephrotomy  for  obstruction  of  the  kidney  by  a 
calculus  in  the  ureter.  An  abscess  formed  in  the  groin  and 
was  opened,  and  three  weeks  later  a  calculus  escajDed  through 
this  opening,  but  an  urinary  fistula  persisted. 

Dr.  Stephen  H.  Weekes  and  Dr.  James  McFaddon  Gaston 
have  published  cases  of  fistula  with  discharge  of  calculi  in 
the  groin. 

In  a  collection  which  I  have  made  of  unselected  cases  of 
fistula  due  to  renal  calculi,  some  of  the  fistulse  followed  the 
bursting  of  pyonephrotic  kidneys ;  and  others  were  the 
result  of  perinephritic  suppuration  and  the  bursting  of  the 
extra-renal  abscess.  Some  opened  spontaneously  into  the 
lung ;  others  into  the  stomach,  or  duodenum,  or  colon  ;  one 
into  the  colon  and  lung,  and  as  both  of  these  organs 
communicated  with  the  renal  pelvis  it  thus  happened  that 
the  lung  communicated  with  the  colon*  Of  those  which 
opened  on  the  external  surface  one  did  so  below  the 
trochanter,  one  between  the  eighth  and  ninth  ribs,  one  or  two 
in  the  groin,  but  the  majority  in  the  loin. 

When  a  perinephric  abscess  burrows  beneath  the  ribs 
and  points  posteriorly  in  an  intercostal  space,  the  course 
taken  by  the  pus  is  through  the  costo-diaphragmatic  hiatus. 
This  hiatus,  formed  by  the  absence  of  the  muscular  fibres 
of  the  diaphragm,  exists  on  both  sides  of  the  trunk,  and 
gives  facility  for  the  ascent  of  pus  between  the  liver  and 
peritoneum,  or  spleen  and  peritoneum  in  front,  and  the  ribs 

*  Specimen  in  St.  Bartholomew's  Hospital. 


86  HUNTEBIAN  LECTURES. 

and  intercostal  muscles  behind.  Judging  from  the  cases  I 
have  seen,  the  lung  is  pushed  upwards  and  the  pleura  up- 
wards and  forwards.  Thus  the  resulting  fistula  can  be  dealt 
with  without  opening  either  pleural  or  peritoneal  cavity. 

A  fistula  of  calculous  origin  may  be  either  in  communi- 
cation with  the  kidney  or  ureter ;  or  may  be  limited  to  the 
perinephric  tissue.  In  one  case  (described  and  illustrated  in 
my  book  on  the  Surgery  of  the  Kidney,  p.  227)  the  fistulous 
track  went  straight  through  from  the  surface  to  the  kidney, 
without  communicating  with  an  abscess  in  the  perinephric 
tissue. 

After  an  operation  in  which  the  kidney  has  been  incised, 
a  fistula  may  end  in  a  smooth-lined  space,  containing  more  or 
less  pus,  and  surrounding  one  or  other  pole  of  the  kidney; 
but  without  any  communication  whatever  with  the  kidney 
or  ureter.  A  fistula  may  have  a  communication  with  the 
renal  cavity  or  ureter  without  there  being  any  escape  of  urine 
through  it;  this  can  in  some  cases  be  demonstrated  by  the 
injection  into  the  fistula  of  an  aqueous  solution  of  fuchsin. 
If  the  communication  is  free  and  direct,  evidence  of  the 
coloured  solution  having  reached  the  bladder  will  be  obtain- 
able in  a  few  minutes,  as  in  Nos.  1  and  2,  Table  VIII. ;  if  the 
communication  is  small  and  indirect,  an  hour  or  two  may 
be  required  before  proof  is  obtained. 

The  closure  of  the  fistula  by  surgical  treatment  is  tedious, 
and  sometimes  impossible;  and  in  some  cases,  after  having 
been  successfully  treated,  and  remaining  closed  for  many 
months,  or  a  year  or  two,  it  will  reopen. 

Fistulse  which  do  not  communicate  with  the  kidney  or 
ureter  should  be.  treated  on  the  ordinary  principles  applicable 
to  all  fistulse ;  those  which  do  so  communicate  must  be 
dealt  with  differently  in  different  cases^Jtf  there  is  a 
calculus  in  the  kidney  it  must  be  removed ;  if  the  kidney 
is  quite  disorganised,  nephrectomy  is  requisite  ;  if  the  kidney 
is  not  disorganised,  the  fistulous  track  should  be  cut  out,  and 
the  cut  surfaces  united  by  sutures.  This  I  did  in  the  case 
of  No.  14,  Table  VII,  with  success.  When  no  stone  is  found 
in  the  kidney,  the  ureter  will  probably  be  the  seat  of  some 
kind  of  obstruction.  There  may  be  an  impacted  calculus  ; 
a   stricture,    following    inflammation    or   ulceration,    caused 


ERRONEOUS  OBJECTIONS    TO   EARLY  OPERATIONS.  87 

by  a  calculus  which  has  escaped,  or  a  stricture  as  the 
result  of  contraction  after  peri-ureteritis ;  or  the  duct  may- 
be distended  in  one  part  and  contracted  in  another  by 
suppurative  ureteritis.  In  most  cases  a  renal  or  ureteral 
fistula,  of  calculous  origin,  will,  I  believe,  close  permanently 
after  nephrectomy,  even  if  a  stone  be  left  impacted  in  the 
ureter,  or  the  ureter  be  in  a  state  of  suppuration  at  the  time 
of  the  operation.  But  should  it  not  do  so,  it  may  be  neces- 
sary, as  in  the  case  of  fistula  kept  up  by  tuberculous  ureteritis, 
to  perform  partial,  or  complete  ureterectomy. 

An  urinary  fistula,  due  to  obstruction  in  the  ureter,  may 
in  time  cease  to  discharge  urine,  owing  to  complete  atrophy 
of  the  kidney.  The  length  of  time  required  for  this  to  be 
accomplished  depends  on  the  degree  of  obstruction  which 
the  fistula  on  the  one  hand,  and  the  ureteral  block  on  the 
other  hand,  offer  to  the  escape  of  urine.  The  more  complete 
the  obstruction,  the  more  rapid  the  atrophy,  and  vice  versa. 
In  a  case  of  my  own  the  process  took  seven  years  (see 
"  Injuries  to  the  Ureter,"  page  153  of  this  work).  Even 
after  a  fistula  <  ceases  to  be  urinous,  it  may  persist  as  a 
suppurating   sinus. 

Two  objections  to  early  operations  for  renal  calculus  are : 
(1)  that  calculi  will  be  missed  if  sought  for  very  early, 
because  of  their  small  size ;  (2)  that  very  small  calculi,  if 
they  once  enter  the  ureter,  pass  through  the  urinary  passages 
without  risk  to  life.  Both  these  objections  are  unsound,  and 
lead  to  dangerous  delay. 

I  am  not  unmindful  that  there  are  cases  on  record,  and 
many  others  which  have  not  been  recorded,  in  which  explora- 
tory operations  have  been  done  and  no  stone  detected,  though 
a  calculus  was  present  either  in  the  kidney  or  ureter  of  the  side 
explored.  This  will  happen  to  operators  who  think  that,  if  a 
stone  is  present,  all  that  has  to  be  done  is  to  cut  down  upon 
the  kidney  and  extract  the  calculus  which  at  once  is  revealed 
to  the  surgeon.  This  teaching  I  have  heard  from  the  lips  of  a 
very  noted  surgeon,  but  nothing  can  be  more  misleading  or 
more  opposed  to  the  conditions  which  exist  in  a  large  number 
of  cases.  Failure  to  find  a  stone  will  also  occur  with  operators 
who  trust  to  needling  the  kidney. 


88  HUNTERIAN  LECTURES. 

It  sometimes  happens  that  though  one  stone  is  found  and 
extracted,  a  second  and  larger  one  escapes  detection  if  the 
kidney  is  not  thoroughly  explored  throughout.  It  is  certainly 
unsafe  to  conclude  because  one  calculus  is  found  that  there  is 
not  another  to  be  discovered.  Thus  after  one  of  my  early 
nephrotomies  for  calculus,  symptoms  persisted  which  led  me  a 
few  weeks  later  to  explore  the  same  kidney  a  second  time,  when 
I  removed  a  calculus  weighing  360  grains,  which  I  had  over- 
looked at  the  first  operation.  This  arose  from  my  being 
satisfied  with  the  removal  of  a  calculus  weighing  26  grains 
and  neglecting  to  thoroughly  explore  the  rest  of  the  kidney. 
(Table  II,  Nos.  3  and  4) 

It  sometimes  occurs  that  the  most  careful  examination  of 
the  kidney  shows  the  absence  of  calculus  in  it,  yet  a  stone  is 
present  in  the  ureter ;  or  a  stone  is  found  in  the  kidney  and  a 
second  is  in  the  ureter.  The  ureteral  calculus  will  be  over- 
looked unless  the  ureter  is  explored  by  a  catheter  or  bougie. 
I  have  had  three  instances  in  my  own  practice  in  which  a 
calculus  has  been  passed  within  a  few  months  after  a  negative 
exploration  of  the  kidney.  I  have  no  doubt  that  in  each  of 
these  cases  the  calculus  was  either  shaken  out  of  the  renal 
pelvis  by  the  manipulation  of  the  kidney  for  the  purpose  of 
bringing  it  to  the  surface  of  the  body,  or  was  impacted  in  the 
ureter  prior  to  the  operation,  and  that  I, failed  to  detect  it 
because  I  did  not  explore  the  whole  length  of  the  ureter.  In 
a  comparatively  recent  case  in  which  I  did  catheterise  the 
ureter  after  incising  and  exploring  thoroughly  the  kidney,  a 
small  ovoid  stone  was  passed  by  the  patient  some  five  months 
after.  In  this  case  I  was  conscious,  when  traversing  the  ureter, 
of  an  obstruction  at  the  brim  of  the  pelvis  ;  but  as  I  could  get  no 
sense  of  grating  upon  anything  like  a  stone,  I  inferred  that  the 
obstacle  was  a  slight  kinking  of  the  ureter,  and  so  neglected^ 
to  expose  and  palpate  the  ureter  as  I  ought  to  have  done. 
(Table  V.,  No.  50.)  If  the  ureter  is  properly  tested  from  end 
to  end  such  disappointments  to  surgeon  and  patient  will  be 
almost  certainly  avoided. 

In  the  lists  of  my  operations  for  calculus,  it  will  be  found 
that  stones  of  all  sizes,  from  two  grains  to  ten  ounces,  have 
been  removed  by  nephrolithotomy  or  nephrotomy;  and  I 
do  not  think  one,  however  small,  ought  to  be  missed  because 


DANGER   OF  SMALL  RENAL   CALCULI. 


89 


of  its  small  size,  with  the  present  method  of  exploring 
the  kidney  and  ureter. 

The  second  objection  is  even  more  invalid  than  the  first ; 
for  there  is  ample  proof  that  a  very  minute  calculus  may  pro- 
voke the  complete  destruction  of  the  kidney,  or  become  the 
immediate  cause  of  death  from  suppression  of  urine. 

The  accompanying  figure  (Fig.  20)  of  a  pyonephrotic  kidney 
shows    the   closure    of  the    ureter  at   its  renal   end   bv  the 


Fia 


20. — A  pyonephrotic  kidney  due  to  calculi  of  minute  size  blocking  the  upper 
end  of  the  ureter.     (Author's  case,  Table  III.,  No.  14.) 


impaction  of  two  tiny  stones,  and  the  entire  destruction  of 
the  kidney  in  consequence.     (Vide  No.  14,  Table  III.) 

In  some  of  my  cases  the  most  continuous  and  profuse 
huematuria  has  been  caused  by  small  stones.  But — worse 
than  hematuria  or  the  destruction  of  a  kidney — calculi 
weighing  less  than  two  grains  have  caused  death. 

Sir  "William  Koberts,  in  his  admirable  chapter  on  "  Obstruc- 
tive Suppression  of  Urine,"  records  a  case  where  three  little 


90  HUNTERIAN  LECTURES. 

oxalate  of  lime  calculi,  about  the  size  of  hemp  seeds,  and 
weighing  altogether  one  grain  and  a  half,  were  found  in  the 
lower  part  of  the  ureter.  One  of  these  was  tightly  impacted 
in  the  terminal  part  of  the  ureter,  where  it  passed  through  the 
coats  of  the  bladder ;  this  was  the  cause  of  the  obstruction 
which  resulted  in  the  death  of  the  patient  from  anuria. 

In  another  case,  he  tells  how  the  secretion  of  urine  was 
suddenly  and  permanently  arrested  by  an  uric  acid  calculus 
about  the  size  and  shape  of  a  hemp  seed,  which  weighed  only 
one  grain  and  a  third,  and  which,  becoming  impacted  in  the 
ureter,  just  above  its  entrance  into  the  bladder,  destroyed  the 
patient  in  less  than  ten  days. 

In  a  third  case  a  similar  course  of  events  was  brought 
about  by  a  round  uric  acid  stone  the  size  of  a  small  pea,  which 
weighed  only  one  grain  and  a  half. 

In  all  these  cases  the  opposite  kidney  had  been  previously 
destroyed  or  obstructed,  and  the  little  calculi  caused  death 
from  anuria  by  obstructing  the  ureter  of  the  hypertrophied 
and  only  kidney,  which  was  acting. 

CALCULOUS   ANURIA. 

Calculous  anuria  is  the  gravest  and  most  fatal  of  the 
many  serious  complications  of  renal  lithiasis.  Special  atten- 
tion was  given  to  it  in  1872  by  Sir  William  Roberts  in  the 
second  edition  of  his  classical  work  on  "  Urinary  and  Renal 
Diseases  "  (p.  23,  et  seq.)  ;  and  in  1881  an  exhaustive  thesis 
on  anuria  by  Pierre  Merklen  was  published  in  Paris;  but 
neither  in  this  nor  in  Roberts'  book  is  the  subject  of  the 
surgical  treatment  of  calculous  anuria  considered. 

In  his  1885  edition,  Sir  William  Roberts,  it  is  true,  says  in  a 
footnote  :  "  Lately  it  has  been  recommended  to  open  the  ureter_ 
or  pelvis  of  the  kidney  above  the  obstruction,  and  so  establish  a 
permanent  urinary  fistula,"  but  though  antispasmodics  and  a 
variety  of  mechanical  means  are  recommended,  and  diuretics 
are  rightly  condemned,  still  surgical  aid  was  not  seriously 
discussed  by  either  Roberts  or  Merklen. 

Even  at  the  present  time  the  principle  of  the  operative 
treatment  of  calculous  suppression  of  urine  is  either  im- 
perfectly known  or  improperly  appreciated  by  the  profession 


CALCULOUS  ANURIA.  91 

in  this  country ;  because  operations  are  certainly  neither 
sufficiently  early  nor  sufficiently  often  performed. 

In  the  first  lecture  I  pointed  out  that  Gigon  of  Angouleme, 
in  1856,  first  suggested  ureterotomy  and  the  establishment 
of  a  lumbar  fistula  in  a  case  of  this  sort. 

Guermonprez  in  1870  (see  t.  xi.,  No.  1)  reported  the  first 
case  operated  upon.  The  next  operation  was  performed  by 
Bardenheuer  in  1882.  The  patient  was  a  female,  aged  thirty- 
seven,  with  anuria  of  forty-eight  hours'  standing.  The  lumbar 
method  was  adopted,  and  a  calculus  was  found  in  the  upper 
orifice  of  the  ureter.  The  stone  was  pushed  back  into  the 
renal  pelvis  and  removed  through  an  incision  in  its  wall* 

In  1883  Bennett  May  and  Clement  Lucas  (Brit.  Med. 
Journ.,  vol.  ii.,  1883)  advocated  nephrotomy  and  the 
establishment  of  a  permanent  fistula  in  cases  of  anuria 
when  one  kidney  is  absent  or  disabled,  and  the  ureter  of 
the  other  kidney  becomes  blocked  by  a  calculus.  This  is 
Gigon's  suggestion  over  again. 

In  1884,  in  an  article  on  "  Calculus  impacted  in  the  Ureter, 
and  the  feasibility  of  removing  it  by  surgical  operation,"t  I 
related  a  case  in  which  for  the  first  time  an  attempt  was  made 
to  remove  a  stone  from  the  lower  end  of  the  ureter  for  the 
cure  of  calculous  anuria.  The  calculus  was  detected  in  the 
intra- vesical  extremity  of  the  ureter,  and  I  endeavoured  to 
remove  it  through  the  bladder  after  dilating  the  female 
urethra.  But  the  attempt  was  ineffectual  for  want  of  a  suit- 
able cutting  instrument. 

Although  Emmet  had  shown  in  1879  that  a  calculus  could 
be  successfully  removed  through  the  roof  of  the  vagina  with- 
out opening  the  peritoneum,  and  had  also  removed  a  stone 
from  the  ureter  after  opening  the  bladder,  it  had  not  then 
been  ascertained  that  the  pelvic  portion  of  the  ureter,  i.e. 
the  part  between  the  brim  of  the  true  pelvis  and  the  bladder, 
could  be  safely  reached  and  incised  by  any  other  route, 
without  running  the  risk  of  causing  intra-peritoneal  urinary 
extravasation. 

In  1884  it  seemed  improbable  that  a  calculus  could  be 
removed  from  the  intra-pelvic  portion  of  the  ureter  without 

*  Centrablatt  fur  Chirnrgie,  Marcb,  1882. 
t  American  Journal  of  Med.  Sciences,  p.  458. 


92  HUNTERIAN  LECTURES. 

opening  the  peritoneal  cavity,  but  I  recommended,  in  the 
article  referred  to,  that  the  intra-vesical  end  of  the  ureter, 
in  both  sexes,  and  as  much  of  the  duct  as  could  be  reached 
when  exploring  the  kidney  through  the  loin  (and  that  is 
practically  the  whole  of  the  abdominal  portion  of  the  ureter), 
should  be  directly  attacked  in  cases  of  calculus  impacted 
in  the  ureter. 

It  has,  hoAvever,  since  been  shown  that  a  calculus  can 
be  successfully  removed  from  the  infra-pelvic  portion  of 
the  ureter  without  opening  the  peritoneum,  and  therefore 
without  exposing  the  patient  to  the  risk  of  urine  escaping 
into  the  peritoneal  cavity. 

In  1885  Israel,  as  well  as  Bardenheuer,  in  Germany, 
successfully  treated  anuria  by  extracting  calculi  from  the 
infundibulum  or  the  adjacent  part  of  the  ureter  by  means 
of  the  lumbar  incision.  In  France  Molliere  of  L}7ons,  in 
1885,  was  the  first  who  operated  for  calculous  anuria.  He 
punctured  the  infundibulum  through  the  renal  parenchyma 
with  the  thermo-cautery  on  the  fifth  day  of  anuria,  but 
though  the  anuria  ceased  the  patient  died  on  the  third  day 
after  the  operation. 

Since  1885  two  or  three  excellent  theses  on  this  subject 
have  appeared  in  France  by  Legueu,  Donnadieu,  Glantenay, 
and  Vailhen ;  and  in  England,  though  nothing  bearing 
generally  on  the  surgical  treatment  of  calculous  anuria  has 
been  published,  some  brilliantly  successful  operations  by  the 
lumbar  route  have  been  reported,  notably  by  Clement  Lucas, 
Ralfe  and  Godlee,  and  Kirkham,  Avho  were  amongst  the  first 
English  surgeons  to  operate  in  these  cases.  Ceci,  in  1887,  in 
a  case  of  anuria,  removed  several  stones  from  the  ureter 
through  the  rectum.     (Table  XL,  No.  10.) 

Etiology. — Calculous   anuria   occurs  when    the   ureter_or_ 
renal  pelvis  of  one  kidney  is  occluded  by  a  calculus  ;  the  other 
kidney  being  absent,  or  atrophied,  or  diseased. 

It  often  affects  persons  in  robust  health,  and  may  be 
sudden  and  complete  in  its  onset.  It  is  then  due  to  the 
cessation  of  function  of  a  kidney  which  has  undergone  com- 
pensatory hypertrophy,  and  which  up  to  the  moment  of 
obstruction  had  been  secreting  the  whole  or  the  chief  part  of 
the  urine. 


ETIOLOGY  OF  CALCULOUS  ANURIA.  93 

Calculous  anuria  is,  in  the  first  place,  a  failure  of  excre- 
tion due  to  obstruction,  but  rapidly  becomes  a  failure  of 
secretion  owing  (1)  to  intra-renal  pressure  on  the  obstructed 
side,  and  (2)  to  reno-  or  utero-renal  reflex  suppression  in  the 
opposite  kidney  if  the  latter  has  taken  any  share  in  the  secre- 
tion up  to  the  time  of  the  commencement  of  the  anuria. 

It  must  be  distinguished  from  the  dysuria,  or  oliguria,  which 
frequently  (though  not  invariably)  accompanies  renal  colic,  and 
passes  off  with  the  attack  of  pain.  This  dysuria  is  attributable 
to  the  reflex  influence  upon  the  vaso-constrictor  nerves  of  the 
kidneys  excited  by  the  irritation  of  the  mucous  membrane  of 
the  renal  pelvis,  or  by  the  stretching  of  the  ureteral  walls, 
and  not  to  any  mechanical  obstruction  to  the  flow  of  urine. 

In  the  most  typical  pathological  condition  of  calculous 
anuria  there  is  occlusion  of  both  ureters  by  calculi.  (See 
Figures  21,  22,  and  23.)  The  statements  herein  made  are 
based  on  two  sets  of  cases  collected — namely,  48  cases  not 
operated  upon,  and  49  operated  upon.  The  last  Table,  XL, 
consists  of  the  collected  cases  operated  upon.  In  56  cases 
the  situation  of  the  calculi  were  noted  to  be  as  follows : — 

1.  In  the  renal  pelvis  and  blocking  the  upper  orifice  of 
the  ureter,  seven  cases.  In  four  of  these,  both  ureters  were 
blocked  at  the  renal  orifices. 

2.  In  the  upper  end  of  the  ureter  30  cases.  Both  ureters 
were  blocked  in  five  of  these  cases.  In  three  there  was 
another  stone  impacted  lower  down  (two  in  the  midpart  and 
one  near  the  bladder). 

3.  In  the  middle  portion  of  the  ureter,  in  seven  cases.  In 
one  case  both  ureters  were  blocked,  and  in  two  others  there 
was  a  second  blockage  by  calculus  higher  up. 

4.  In  the  lower  end  of  the  ureter,  in  10  cases.  In  one  of 
these  there  was  an  impacted  stone  also  higher  up,  in  three 
of  them  both  ureters  were  obstructed. 

5.  In  two  cases  complete  suppression  was  caused  by 
"obstruction  of  both  kidneys  by  a  large  vesical  calculus.  (See 
specimen  in  Middlesex  Hospital  Museum  and  Amoden's  case 
recorded  in  the  Bull,  de  Societe  Anatomique,  1875.) 

There  are  two  classes  of  calculous  anurics — the  gouty,  fat, 
and  apparently  robust  adult  past  middle  age ;  and  the  thin, 
nervous  and  dyspeptic  person. 


■■  t»»   *  " 


Fig.  21. — Horse-shoe.  Kidney  with  a  calculus  in  each  ureter.     Post-mortem 
specimen.     (Middlesex  Hospitcd  Museum.) 


ETIOLOGY  OF  CALCULOUS  ANURIA. 


95 


Anuria  may  occur  at  any  age  and  in  either  sex  ;  it  is  more 
frequent  in  males  of  thirty-five  years  and  upwards,  and  more 
especially  in  elderly  men.  Instances  of  children,  and  even 
infants  at  the  breast,  dying  of  convulsions  from  calculous  sup- 
pression have  been  recorded  (Rayer) .    Out  of  81  cases  collected, 


Fig.  22. — Ureters  packed  with  calculi.  The  calculi  in  the  ureter  laid  open 
are  represented  in  the  drawing  arranged  precisely  as  they  were  found 
after  death.     (Middlesex  Hospital  Museum.) 


in  which  the  sex  and  ag^e  are  stated,  there  were  54  males 
and  27  females.  Forty-three  out  of  the  81  occurred  in 
persons  between  40  and  60  ;  15  over  60  years;  19  between 
20  and  40 ;  one  before  10  years  of  age  and  three  between  10 
and  20.     The  youngest  was  aged  six,  and  the  oldest  80. 

Much  importance  ought  to  be  attached  to  the  antecedent 


96 


HUNTEBIAN  LECTURES. 


history  of  patients  who  become  the  subjects  of  suppression 
of  urine  from  ureteral  obstruction.  Commonly  they  have 
had  several  previous  attacks  of  renal  colic,  or  of  lumbar 
pains,  followed  by  the  discharge  of  gravel  or  small  stones, 
months,  or  even  years,  before  the  attack  in  which  the  anuria 
begins.  But  cases  have  occurred  of  sudden  suppression  of 
urine   from   obstruction   by   a   calculus    without   a   previous 


Fig.  23. — The  two  kidneys  of  the  same  person,  each  blocked  with  a  calculus. 
The  one  first  affected  is  atrophied,  the  other  has  been  hypcrtrophied, 
and  is  becoming  granulated.     (Middlesex  Hospital  Museum.) 

attack  of  any  kind.     In  such  cases  both  kidneys  have  been 
simultaneously  obstructed,  or  one  kidney  has  been  destroyed^ 
by  disease  of  another  kind,  or  has  been  congenitally  absent 
or  abnormal. 

Calculous  anuria  is  often  determined,  or  immediately 
induced,  by  fatigue ;  a  drive,  or  some  other  shaking  move- 
ment, such  as  jumping  from  an  omnibus,  violent  cough- 
ing, running  rapidly,  are  some  of  the  causes,  in  my  own 
cases,  which  started  the  descent  of  the  calculi  from  the 
kidney   into  the  ureter. 


SYMPTOMS    OF    CALCULOUS    ANURIA.  97 

Symptoms. — The  symptoms  of  calculous  anuria  are  not 
simply  those  of  uraemia.  They  also  differ  in  their  mode  of 
onset,  and  in  their  character,  from  some  other  forms  of 
obstructive  anuria,  such  as  anuria  from  cancer  of  the  uterus ; 
from  the  pressure  of  abdominal  tumours ;  and  from  torsion, 
curves,  or  stricture  of  the  ureter  ;  as  well  as  from  toxic,  reflex, 
and  hysterical  and  other  non-obstructive  forms  of  anuria. 

When  the  ursemic  symptoms  set  in  they  exhibit  marked 
differences  from  the  uraemia  of  lardaceous  disease,  of  Briolit's 
disease,  and  of  other  forms  of  nephritis. 

Though  in  rare  instances  the  onset  is  insidious,  pain  is 
almost  invariably  experienced  in  the  region  of  the  kidney 
involved  last,  at  the  outset  of  the  suppression.  The  pain  so 
started  may  continue  throughout  the  anuria,  but  more 
commonly  it  is  temporary,  lasting  only  a  day  or  two,  or 
less,  and  then  subsiding.  Less  frequently  the  first  symptom 
is  a  dull  and  continuous  aching  in  the  lumbar  region, 
with  or  without  pains  radiating  along  the  course  of  the 
ureter.  In  very  exceptional  cases  the  anuria  has  come  on 
without  pain  on  either  side,  and  without  the  history  of 
previous  attacks  of  renal  colic ;  or  the  patient  has  quite 
forgotten  on  which  side  the  previous  attacks  of  colic  were. 
These,  fortunately  rare,  are  the  cases  in  which  the  surgeon 
may  have  no  guide  as  to  which  kidney  to  operate  upon. 

With  the  pain  there  may  be  troubles  of  micturition,  such 
as  continual  desire  to  pass  water,  though  not  a  drop  of  urine 
may  be  in  the  bladder ;  or  the  urine  is  passed  with  difficulty, 
and  sometimes  only  in  drops  or  teaspoonfuls.  Or,  on  the 
contrary,  there  may  be  polyuria,  the  urine  being  pale  and 
of  low  density,  and  showing  evidence  of  imperfect  renal 
function.  In  other  cases  the  anuria  is  intermittent,  ceasing, 
after  some  hours  or  a  few  days,  to  reappear,  and  become 
definitely  established. 

Calculous  anuria  may  be  complete  or  incomplete.  In  the 
complete  suppression  the  bladder  is  quite  empty,  or,  if 
not,  contains  but  a  few  teaspoonfuls  of  bloody  urine.  In  the 
incomplete  form,  the  anuria  is  intermittent,  but  progressive, 
and  interrupted  by  discharges  of  urine,  insufficient  to  satisfy 
the  requirements  of  the  system,  but  sufficient  to  retard  the 
fatal  termination  of  the  disease.     When  the  working  kidney 


98  IWNTERIAN  LECTURES. 

is  hydronephrotic  the  ursemic  condition  may  be  deferred  for 
a  longer  time  than  otherwise,  even  if  there  are  no  polyuria 
intermissions. 

Calculous  anuria,  once  established,  may  last  many  days 
without  causing  any  symptoms  of  uraemia.  This  is  perhaps 
its  most  striking''  feature,  which  it  shares  with  other  forms 
of  obstructive  anuria,  as  distinct  from  the  non-obstructive 
forms.  Even  when  the  suppression  is  complete,  seven, 
eight,  or  ten  days  may  elapse  before  the  symptoms  of 
ursemia  appear,  and  sometimes  death  occurs  without  any  of 
the  characteristic  symptoms  of  ursemic  poisoning  arising  at 
all.  When  the  ursemic  phenomena  supervene  after  a  longer 
or  shorter  time,  death  follows  rapidly,  or,  at  any  rate,  within 
a  day  or  two.  Thus  it  happens  that  authors  have  come 
to  distinguish  two  stages  in  the  progress  of  calculous  anuria ; 
namely,  (1)  the  silent  or  tolerant  period ;  and  (2)  the  ursemic 
period.  But  it  is  important  to  remember  that  death  may 
occur  as  just  mentioned  without  the  supervention  of  the 
second  or  ursemic  period  occurring. 

(1)  Symptoms  of  the  tolerant  stage.— In  the  period  of 
tolerance,  the  patient,  though  he  may  not  pass  a  single  drop 
of  urine  for  several  days,  may  yet  walk  about,  eat,  and  do 
mental  work  in  all  the  appearance  of  good  health.  This 
fact  must  never  be  forgotten,  if  a  serious  mistake  in  diagnosis 
and  prognosis  is  to  be  avoided.  It  is,  however,  all  the  more 
likely  to  escape  notice,  because  it  is  so  opposed  to  the  course 
of  suppression  due  to  non-obstructive  causes. 

In  the  non-obstructive  forms  of  suppression,  e.g.  in  chronic, 
sub-acute,  and  acute  forms  of  Bright's  disease ;  in  suppression 
from  shock  or  collapse,  as  after  severe  internal  injury,  and  in 
the  algide  stage  of  cholera  or  yellow  fever;  in  all  forms  of 
inflammation  and  fever ;  and  in  the  suppression  of  oirine^ 
after  slight  operations  on  the  urethra  or  bladder,  death  may 
occur  within  twelve  or  twenty-four  hours.  In  these  cases 
there  will  be  symptoms  of  ursemic  poisoning,  but  death 
would  seem  to  be  too  rapid  to  be  explained  simply  by  the 
non-elimination  of  urinary  excreta.  Moreover,  if  the  sup- 
pression ceases,  the  return  of  the  secretion  is  gradual,  and 
the  first  quantities  of  urine  secreted  are  scanty,  albuminous, 
and  perhaps  bloody. 


SYMPTOMS    OF    CALCULOUS    ANURIA.  99 

On  the  other  hand,  in  the  calculous  cases,  the  sup- 
pression of  urine  may  last  days,  and  if  the  anuria  should 
cease  temporarily,  or  permanently,  free  secretion  is  resumed ; 
and  the  urine  passed  is  of  low  specific  gravity,  and  pale  in 
colour ;  and  even,  though  it  may  contain  blood,  it  is  defective 
in  the  ordinary  urinary  constituents. 

The  lumbar  or  nephritic  pain  which  ushers  in  obstructive 
anuria  often  ceases  as  soon  as  the  pressure  of  the  pent-up  urine 
in  the  renal  cavity,  and  the  pressure  of  the  blood  within  the 
renal  vessels,  are  equalised.  It  is  only  in  exceptional  cases, 
where  previous  intermittent,  or  imperfect  obstruction  has 
induced  a  condition  of  hydronephrosis  in  the  kidney  involved, 
that  anuria  is  accompanied  by  persisting  pain. 

Another  striking  feature  is  that  anuria  caused  by  calculus 
is  rarely  quite  complete  from  the  beginning  to  the  end  of  the 
illness.  At  different  intervals  some  drops,  ounces,  or,  it  may 
be,  even  pints  of  urine — pale,  limpid,  of  low  specific  gravity, 
poor  in  urea,  in  urinary  salts,  and  in  the  urinary  colouring 
matter — are  voided. 

"  The  characters  of  this  urine,"  says  Merklen,  "  are  so 
decisive  that  they  strike  the  patient  as  much  as  the  doctor. 
Its  density  rarely  exceeds  1006-1008;  it  is  only  rarely 
albuminous,  but  sometimes  it  contains  blood  and  epithelial 
casts.  Owing  to  its  indifferent  excrementitious  character 
these  discharges  of  urine  have  but  slight  influence  on  the 
final  result ;  the  total  amount  of  urea  eliminated  by  a 
patient  throughout  an  anuric  crisis  being  insignificant." 

Of  course,  in  cases  of  calculous  pyelitis,  or  disorganisation 
of  one  or  both  kidneys,  the  urine  may  also  contain  pus  as 
well  as  blood,  and  renal  casts  and  epithelium,  and  yet  be 
deficient  in  the  normal  urinary  solids. 

In  certain  cases,  as  in  those  recorded  by  Paget  and  Weber, 
polyuria  occurs,  and  retards  the  appearance  of  ursemic  pheno- 
mena as  well  as  the  fatal  termination,  which,  however,  at 
length  arrives  just  the  same. 

In  Paget's  case  polyuria  occurred  on  the  thirteenth  day, 
and  death  was  deferred  till  the  twenty-second  day.  In 
Weber's  case  a  succession  of  remissions  of  polyuria  took  place, 
and  the  fatal  result  was  not  reached  till  the  thirtieth  day. 

In   one   of  Roberts'  cases  the  patient  lived  fifteen  days. 


100  HUNTEBIAN  LECTURES. 

Tenneson  (Gaz.  Hebdom.,  1879)  reported  a  fatal  case  in 
which  the  suppression  lasted  fifteen  days.  Dr.  Ernst  Bischoff 
reported  the  case  of  a  man  at  fifty-eight,  who  for  fourteen 
years  had  suffered  from  gout  and  lithiasis ;  he  had  had 
repeated  temporary  suppression  for  several  days  together; 
then  twenty- three  days  of  anuria,  with  two  very  slight  inter- 
missions on  the  fifth  and  fourteenth  days,  attended  by  oedema, 
fever,  and  aphthous  stomatitis  and  very  high  temperature. 
The  post-mortem  showed  a  very  small  left  kidney,  but  in  a 
state  tending  towards  compensatory  hypertrophy,  with  calculi 
in  both  ureters  and  in  the  left  renal  pelvis. 

In  one  of  my  own  cases  there  were  two  periods  of 
complete  anuria  for  forty-eight  hours  or  more,  with  inter- 
missions, during  which  there  was  a  more  or  less  free  secretion 
for  eleven  days  ;  then  three  days  when  the  daily  secretion  was 
10  ounces,  6|  ounces,  and  1  ounce  respectively ;  and  lastly, 
four  days  of  complete  suppression  preceding  death  on  the 
eighteenth  day  from  the  onset  of  the  anuria. 

In  the  stage  of  tolerance,  though  the  general  health  is  at 
first  but  slightly  if  at  all  affected,  yet  after  three  or  four  or 
five  days  some  symptoms  arise,  referable  to  the  digestive 
organs,  such  as  eructations,  nausea,  constipation,  flatulence, 
and  a  white-furred  tongue ;  or  referable  to  the  nervous  system, 
such  as  mental  depression,  a  sense  of  lassitude  and  disturbed 
sleep,  or  actual  sleeplessness.  But  these  symptoms  are  not 
constant,  and  if  they  exist,  may  be  so  slight  as  to  pass 
unnoticed,  especially  if  the  anuria  should  terminate  spon- 
taneously. 

In  some  cases  during  this  stage  the  desire  to  urinate  is 
strong  and  persistent.  There  may  be  a  sense  of  weight  and 
fulness  about  the  bladder,  and  tingling  at  the  end  of  the 
pelvis  which  lead  the  patient  to  believe  he  is  unable— 
to  empty  a  distended  bladder,  and  to  seek  relief  by 
catheter  for  supposed  retention,  when  the  real  condition  is 
suppression. 

Symptoms  of  the  tolerant  stage  when  hydronephrosis  is 
associated  with  anuria. — When  the  working  kidney  is 
hydronephrotic,  patients  with  calculous  anuria  may  escape 
ursemic  accidents  for  a  much  longer  time  than  others,  without 
having  polyuric  remissions. 


HYDRONEPHROSIS    IN  CALCULOUS  ANURIA.        101 

Thus  in  a  fatal  case  of  a  man  aged  sixty-four  recorded  by 
Rayer  (Mai.  des  Reins,  t.  iii.  p.  490),  with  an  enormous 
hydronephrosis,  the  anuria  lasted  twenty-five  days,  with  only 
a  slight  remission  on  the  tenth  day.  James  Russell  published 
a  case  of  anuria  lasting  twenty  days,  which  terminated  by  the 
discharge  of  10  litres  of  urine  in  twenty- four  hours  ;  but  a 
year  later  the  patient  died,  and  at  the  post-mortem  examina- 
tion there  was  discovered  double  hydronephrosis  with  calculi 
in  the  pelvis  of  each  kidney. 

Roberts  cites  a  case  of  calculous  anuria  of  ten  days'  dura- 
tion, with  an  increasing  tumour  in  the  left  iliac  fossa ; 
recovery  followed  a  veritable  urinary  crisis  coincident  with 
the  disappearance  of  the  tumour. 

But  whilst  hydronephrosis  is  exceptional  in  calculous 
anuria,  and  such  marked  poly  uric  remissions  are  uncommon, 
it  is,  on  the  other  hand,  much  more  frequent  for'the  secretion 
of  urine  to  cease  definitely,  shortly  after  the  establishment 
of  the  obstruction. 

Hydronephrosis  occurs  only  when  anuria  is  repeated  on 
many  occasions,  for  a  brief  period  only,  or  in  an  incomplete 
manner :  that  is  to  say,  when  the  obstruction  is  intermittent, 
or  imperfect  and  progressive.  Thus  in  one  of  my  cases  com- 
plete anuria,  accompanied  with  pain  and  a  tumour  in  the 
left  renal  region,  occurred  on  many  occasions,  lasting  two  or 
three  days  at  a  time.  The  right  kidney  was  packed  with 
calculi,  calculi  being  felt  to  grate  on  one  another,  and  the 
left  kidney,  which  had  undergone  compensatory  hypertrophy, 
was  in  an  early  stage  of  hydronephrosis,  and  contained  a 
single  round  calculus  the  size  of  a  small  cherry,  which  was 
freely  movable  in  the  renal  cavity.  The  left  ureter  was 
unobstructed  and  normal  throughout. 

In  Wilcox's  case  there  were  many  crises  of  nephritic  colic 
with  anuria,  terminated  by  diuresis,  and  death  ensued  at  last 
from  rupture  of  a  hydronephrotic  kidney  after  six  days  of 
anuria. 

It  is  in  cases  of  anuric  hydronephrosis  such  as  this, 
and  also  those  of  Rayer,  Weber,  James  Russell,  and  Roberts, 
in  which  marked  polyuria  announced  the  re -establishment 
of  the  secretion  of  the  urine,  that  operative  treatment  is 
most  likely  to   succeed.     An  early  operation  in  such  cases 


102  HUNTEBIAN  LECTURES'. 

would  lead  to  the  discovery  and  removal  of  the  cause  of  the 
hydronephrosis,  as  well  as  of  the  anuria,  and  would  save  the 
kidney  from  progressive  degeneration,  and  the  patient  from 
fatal  suppression  of  urine. 

The  fact  that  the  opposite  kidney  is  functionless  and 
destroyed  is  an  additional  reason  for  operating,  not  a  contra- 
indication for  so  doing,  as  it  is  too  often  considered  to  be. 
It  was  so  regarded  in  the  case  of  my  patient,  yet  the  actual 
result  of  the  operation  was  all  that  could  be  desired.  (Table 
I,  No.  34.) 

(2)  Symptoms  of  the  urcemic  stage. — At  a  variable  period 
the  second  or  ursemic  stage  sets  in.  When  the  anuria  is 
complete  this  period  arrives  mostly  about  the  seventh  or 
eighth  day.  For  a  time  no  doubt  the  poisoned  state  of 
the  circulation  is  relieved  by  the  supplementary  elimination 
through  the  skin,  lungs,  and  digestive  mucous  membrane. 
But  sooner  or  later  these  organs  are  insufficient  for  the  task, 
and  themselves  become  vitiated  by  the  unaccustomed  func- 
tions they  are  called  upon  to  perform;  then  the  blood 
becomes  surcharged,  and  in  turn  the  nervous  system  comes 
under  the  influence  of  the  uneliminated  poison.  But  why  this 
effect  is  so  much  more  tardily  produced  in  calculous  anuria 
than  in  non-obstructive  uraemia  is  not  known. 

The  symptoms  of  the  uremic  stage  may  be  summarised 
under  three  groups  (a)  the  circulatory,  (6)  those  connected 
with  elimination,  and  (c)  those  of  poisoning. 

(a)  The  pulse  is  slow  and  full  and  later  becomes  irregular. 
Epistaxis  in  one  case  was  very  abundant  ;  oedema  about  the 
malleoli  and  even  a  true  anasarca — the  result  of  venous  stasis, 
not  of  albuminuria — have  been  observed  in  a  few  cases  by 
Sir  William  Roberts,  Russell,  Ernst  Bischoff,  Tenneson, 
and  Merklen.  The  temperature  is  low,  as  in  all  forms__of^ 
uraemia,  viz.,  from  97  to  97*6. 

(6)  Profuse  perspirations  may  occur,  but  if  so,  are  sup- 
pressed in  the  last  day  or  two  of  life.  The  older  writers  state 
that  the  sweat  has  the  odour  of  urine;  but  modern  writers 
following  Roberts  dispute  this.  Roberts,  indeed,  goes  further, 
for  he  says  (4th  ed.,  p.  34)  "  there  is  never  any  ainmoniacal  or 
urinous  odour  from  the  breath  or  skin,  nor  from  the  body 
after  death."     In  one  of  my  cases,  in  which  there  had  been 


UBJEMIG    STAGE    OF    CALCULOUS    ANURIA.  103 

suppression  for  nine  days,  Mr.  Steedman  wrote  me  that  about 
twelve  hours  before  death  the  patient's  "  extremities  became 
cold  and  clammy,  her  face  swollen,  and  the  breath  strongly 
ammoniacal.  The  body  began  to  be  offensive  a  few  hours 
after  death." 

In  the  absence  of  sweats,  cases  of  itching  of  the  skin, 
pruriginous  eruptions,  and  erysipelatous  swelling  of  the 
whole  body  are  quoted  by  Rayer ;  profuse  salivation  is 
noted  by  Weber;  blood-stained  expectoration  by  Foissac 
and  Paget. 

But  more  important  than  the  foregoing  symptoms  is 
vomiting.  This  is  copious  and  due  to  gastric  irritability 
rather  than  to  supplementary  elimination.  It  is  a  symptom 
of  bad  omen,  which  precedes  and  accompanies  the  ursemic 
nervous  phenomena.  Obstinate  constipation  and  meteorism 
are  common  intestinal  symptoms.  Meteorism  may  be  par- 
ticularly troublesome.  Sometimes  there  is  a  veritable 
intestinal  paralysis.  Diarrhoea,  so  common  and  marked  a 
symptom  in  my  experience,  in  some  cases  of  uraemia 
from  lardaceous  disease,  is  very  exceptional  in  calculous 
anuria. 

(c)  Contraction  of  the  pupils  and  muscular  tremors  are 
the  two  most  marked  symptoms  of  the  poisoning  stage. 
There  are  not  the  great  general  disturbances  which  acute 
nephritis  and  Bright's  disease  cause.  The  dominant  feature 
of  fatal  anuria  is  complete  depression  of  body  and  mind. 
The  intelligence  may  be  perfect  to  the  last  moment,  but 
more  often  it  becomes,  after  a  while,  impaired,  the  patient 
being  in  a  state  of  semi-sleep,  from  which,  however,  he  is 
easily  aroused.  Occasionally  delirium  or  hallucinations  occur. 
Incessant  restlessness  and  an  overpowering  feeling  of  heaviness 
and  general  fatigue  are,  when  they  exist,  the  immediate  pre- 
cursors of  death.  The  limbs,  instead  of  being  affected  by 
muscular  twitchings  and  agitations,  may  be  benumbed  or 
as  if  paralysed.  The  temperature  falls  lower  with  the 
progress  of  the  disease.  The  respiration  becomes  slow  and 
sighing  and  irregular,  and  the  patient  dies  from  paralysis 
or  powerlessness  of  his  respiratory  muscles.  Or  the  patient 
may  die  of  heart  failure,  without  a  convulsion,  without  coma ; 
occasionally  death  is  caused  by  coma,  or  a  convulsive  crisis ; 


104  HUNTEBIAN  LECTURES. 

and  sometimes   by  an   attack    of  suffocation,    two   or   three 
days  after  the  commencement  of  the  uraemia. 

Prognosis. — The  usual  termination  of  calculous  anuria 
when  left  to  itself  is  death  about  the  tenth  or  eleventh  day. 
If,  however,  the  suppression  is  interrupted  by  intermittent 
polyuria,  whether  hydronephrosis  exists  or  not,  life  may  be 
prolonged  by  many  days.  Spontaneous  cure  sometimes 
occurs.  Legueu  states  that  out  of  56  cases  of  calculous 
anuria,  which  neither  followed  nor  were  treated  by  opera- 
tions, recovery  took  place  in  16 ;  i.e.  in  28*5  per  cent.  In 
one  the  secretion  recommenced  on  the  third  day ;  in  10 
between  the  fifth  and  tenth  days  ;  and  in  the  rest  on  the 
thirteenth,  fourteenth,  fifteenth,  twentieth,  and  in  two  in- 
stances on  even  a  still  later  day.  Of  the  40  deaths  23 
occurred  between  the  fifth  and  fifteenth  days,  one  on  the 
fourth  day,  and  the  rest  on  and  after  the  sixteenth  day. 

Of  the  48  cases  in  my  table  of  cases  not  operated  upon, 
38  died  and  10  recovered ;  of  the  49  cases  operated  upon, 
24  died  and  25  recovered.  Thus  there  is  a  percentage  of 
recoveries  in  cases  operated  upon  of  51  as  against  20'8  in 
cases  not  operated  upon.  These  figures  speak  loudly  in 
favour  of  operation  for  calculous  anuria. 

Merklen  says  that  while  it  is  uncertain  up  to  what  date  we 
may  hope  for  spontaneous  recovery,  the  chances  of  recovery 
diminish  with  the  prolongation  of  the  anuria.  According 
to  Sir  William  Roberts,  the  fatal  termination  is  at  hand 
when  contraction  of  the  pupils  and  convulsive  tremors  of 
the  limbs  occur.  Recovery,  he  thinks,  may  be  hoped  for 
as  long  as  these  phenomena  have  not  been  observed. 

Spontaneous  recovery  from  an  attack  of  anuria  is  an- 
nounced by  an  abundant  polyuria,  or  by  the  discharge  of 
gravel,  blood  clot,  or  calculi.  The  re-establishment  of  Jjhe_ 
secretion  is  often  immediately  preceded  by  the  free  action 
of  the  bowels,  or  by  the  escape,  per  rectum,  of  an  abundant 
quantity  of  intestinal  gas. 

The  polyuria,  Avhich  commences  the  spontaneous  cure, 
lasts  many  days,  and  consists  in  the  discharge  of  immense 
quantities  of  urine  at  short  intervals.  This  polyuria  is  often 
associated  with  albuminuria.  The  urine  discharged  after 
the  expulsion  of  a  calculus  is  generally  albuminous.      The 


PATHOLOGICAL  ANATOMY  OF  CALCULOUS  ANURIA.    105 

amount  of  albumen  is  slight,  but  it  continues  as  long  as  the 
polyuria. 

When  a  first  attack  of  anuria  has  been  of  short  duration, 
and  then  ends  spontaneously,  recovery  may  be  complete,  as  the 
calculus  which  caused  it  may  have  escaped  from  the  ureter. 
When  the  anuria  has  been  recurrent,  or  of  long  duration  and 
complete,  the  recovery,  if  it  occurs,  is  imperfect ;  and  the 
individual,  possessed  as  he  is  of  only  one  active  kidney,  will 
have  a  precarious  existence,  perpetually  threatened  by  another 
attack,  from  which,  in  great  probability,  he  will  not  escape 
with  the  same  good  result.  There  should  therefore  be  no  delay 
in  operating  in  cases  of  relapsing  attacks  of  anuria,  even  when 
these  attacks  are  incomplete  and  of  short  duration. 

The  pathological  anatomy  of  calculous  anuria  may  be 
summed  up  in  the  statement  that  the  ureter,  or  renal  pelvis, 
of  one  side  has  become  recently  occluded,  whilst  the  kidney 
of  the  other  side  is  either  congenitally  absent  or  functionally 
suppressed,  or  structurally  destroyed  by  calculus,  or  some  other 
form  of  renal  disease.  Rarely  does  simultaneous  obstruction 
of  both  ureters  by  calculi  occur,  although  this  has  been 
known  to  happen.  In  one  published  case  (Amoden's),  a  large 
stone  embedded  in  the  trigonal  area  of  the  bladder,  simul- 
taneously obliterated  the  vesical  orifices  of  both  ducts,  and  the 
same  condition  was  found  in  a  case  which  ended  fatally  in 
the  Middlesex  Hospital. 

When  the  calculi  occupy  the  renal  pelvis  they  may  either 
cause  complete  obliteration  by  their  bulk,  or  may  act  as  a 
ball  valve  over  the  upper  end  of  the  ureter. 

Never,  according  to  Merklen,  has  calculous  occlusion  of 
one  ureter  given  rise  to  fatal  anuria,  if  the  kidney  and  ureter 
of  the  opposite  side  are  normal. 

Legueu,  from  an  analysis  of  thirty  cases,  in  which  there 
were  post-mortem  examinations,  found  that  on  the  side  last 
obstructed  there  was  obliteration  of  the  ureter  in  twenty-three 
instances,  and  calculi  in  the  pelvis  of  the  kidney  in  the 
other  seven.  On  the  other  side  there  was  congenital  absence 
of  the  kidney  in  three  cases,  atrophy,  or  other  change 
caused  by  calculus,  in  twenty,  and  obliteration  of  the  ureter 
in  six. 

In  one  case,  and  in  one  only,  was  there  nothing  more  than 


106  HUNTEBIAN  LECTURES. 

a  slight  epithelial  proliferation  of  the  tubules.  Still,  though 
this  was  insignificant  in  degree,  it  was,  nevertheless,  enough  to 
alter  the  functional  capacity  of  the  organ. 

Legueu  found  only  two  instances  of  fatal  anuria  in  persons 
with  one  kidney  sound.  These  are  the  cases  of  Bourgeois 
(Guyon  and  Tuffier,  Ann.  des  Mai.  gen-urin.,  1888)  and 
Nepveu,  and  in  one  of  these  the  anuria  was  traumatic. 

In  twenty-eight  cases  of  those  in  my  lists,  in  which 
the  state  of  the  two  kidneys  is  given,  the  condition  of 
the  principal  kidney  was  enlarged  in  eight,  enlarged  and 
congested  in  four,  small  in  two,  pyronephrotic  in  six,  and 
hydronephrotic  in  eight.  The  condition  of  the  opposite 
kidney  was  as  follows  :  No  trace  existing  in  six  cases  ;  marked 
atrophy  in  eight,  in  two  of  which  the  ureter  had  become 
impervious ;  almost  entirely  disorganised  by  calculus  in 
eleven ;  destroyed  by  a  hydatid  cyst  in  one ;  enlarged  in 
two. 

But  though  there  is,  as  a  rule,  a  pronounced  and  long- 
standing alteration  in  one  kidney  before  the  other,  and  func- 
tionally active,  organ  becomes  obstructed,  still,  in  a  proportion 
of  instances,  the  long-damaged  organ  had  been  doing  a 
certain  amount  of  excretion  up  to  the  moment  of  the  onset 
of  the  anuria.  This  impaired  function  becomes  quite  sup- 
pressed by  the  inhibitory  reflex  influence,  due  to  the  sudden 
occlusion  of  the  good  kidney. 

In  short,  if  we  leave  on  one  side  the  rare  instances  in 
which  both  ureters  become  simultaneously  occluded,  we  see, 
as  Legueu  points  out,  that  three  factors  are  required  to 
produce  calculous  anuria. 

(1)  A  long-standing  change  in  one  of  the  kidneys,  causing 
a  diminution,  if  not  suppression,  of  its  function ;  or  else  a 
congenital  anomaly  (absence  or  atrophy). 

(2)  A  recent,  or  recently  aggravated,  lesion  of  the 
principal  kidney.  This  lesion  is  mechanical,  and  caused 
by  calculus. 

(3)  A  reflex  inhibitory  effect  upon  the  disorganised 
kidney,  leading  to  complete  suppression  of  its  imperfect 
functional  power. 

Whilst  the  surgeon  can  do  nothing  for  the  first  of  these 
defects,  he  can  remove  the  cause  of  the  second,  and  thereby 


PATHOLOGICAL  ANATOMY  OF  CALCULOUS  ANURIA.    107 

correct  the  third.  Or  if  he  cannot,  by  removing  the  ob- 
struction, re-establish  the  flow  of  urine  along  the  ureter,  he 
can  create  an  artificial  opening — an  urinary  fistula — and 
thereby  relieve  the  suppressed  function  of  the  principal 
kidney,  and  very  probably  the  reflex  suppression  of  the 
other. 

Out  of  twenty-three  cases  of  ureteral  impaction,  the  cal- 
culus was  found  in  the  upper  extremity  in  thirteen,  and  in 
the  vesical  extremity  in  six.  In  four  cases  the  stone  was 
situated  at  some  intermediate  point. 

If  to  the  thirteen  cases  of  high  ureteral  impaction  are 
added  the  seven  cases  in  which  the  calculi  occupied  the 
infundibulum,  we  find  twenty  out  of  thirty  cases  in  which 
the  stone  could  be  removed  by  an  ordinary  exploration  of 
the  kidney. 

The  dilatation  which  takes  place  behind  a  sudden  obstruc- 
tion is  very  moderate,  so  that  the  quantity  of  urine  in  the 
ureter  and  renal  cavity  is  very  small.  The  pelvis  of  the 
kidney  contains  only  a  little  urine,  which  is  frequently  blood- 
stained. The  kidney  itself  is  hypertrophied  and  congested, 
and  thereby  enormously  increased  in  volume  ;  but,  as  a  rule, 
it  is  not  hydronephrotic.  Numerous  cases  prove  that  im- 
paction of  a  calculus  in  the  ureter  is  much  more  likely  to  be 
followed  by  an  immediate  arrest  of  the  secretion  of  urine  than 
by  retention  of  urine,  and  dilatation  of  the  parts  above  the 
seat  of  obstruction ;  because  the  ureter  and  renal  pelvis  are 
not  susceptible  of  sudden  dilatation. 

Ecchymoses  on  the  surface  and  in  the  substance  of  the 
kidney,  true  infarcts,  are  lesions  which  have  been  obtained  by 
experimental  ligation  of  the  ureter,  and  have  been  found  in 
some  cases  of  obstruction  at  the  time  of  operating,  and  in 
others  at  the  post-mortem  examination. 

When  the  obstruction  has  been  intermittent,  or  imperfect 
and  progressive,  instead  of  being  sudden  and  complete,  hydro- 
nephrosis will  be  found. 

The  cases  of  hydronephrosis  are,  however,  very  exceptional, 
although  slight  dilatation  of  the  calyces  and  numerous  small 
cysts  in  the  cortex  are  common  conditions. 

The  above  are  the  changes  which  involve  the  principal 
kidney,  and  lead  immediately  to  anuria. 


108  HUNTEBIAN  LEG  TUBES. 

The  changes  in  the  other  kidney  are  of  more  or  less 
ancient  date,  and  have  been  possible  of  production  owing  to 
the  integrity  of  the  opposite  kidney.  Simple  atrophy,  with- 
out hydronephrosis,  is  one  of  the  most  frequent  consequences 
of  old  calculous  obstruction  of  the  ureter. 

The  sudden  obstruction  of  one  organ,  whether  by  ligature 
or  disease,  when  the  other  is  intact,  culminates  in  atrophy 
without  dilatation.  In  the  same  way  the  sudden  obstruction 
of  a  single  kidney  causes  almost  immediate  suppression,  and 
not  hydronephrosis. 

Hydronephrosis  with  great  thinning  of  the  parenchyma  is, 
however,  sometimes  found.  In  these  cases  the  calculus 
which  has  been  the  starting  point  of  the  hydronephrosis, 
may  have  long  ago  escaped,  leaving  behind  a  condition 
which  results  in  a  strictured,  or  even  an  impermeable 
ureter. 

Diagnosis. — The  occurrence  of  former  attacks  of  renal  colic 
in  a  gouty  person,  followed  by  the  sudden  onset  of  pain 
on  one  side,  and  this  accompanied  or  immediately  followed 
by  anuria,  points  at  once  to  obstruction  of  a  calculous 
nature. 

The  diagnosis  will  be  further  strengthened  if  a  swelling, 
or  distinct  tenderness  on  pressure,  is  present  in  the  renal 
region,  or  in  the  course  of  the  ureter,  of  the  side  recently 
become  the  seat  of  pain. 

But  in  some  cases  there  is  not  a  distinct  history  of  previous 
attacks  of  renal  colic,  and  yet  one  kidney  may  have  become 
silently  but  entirely  obstructed,  or  destroyed  by  calculi,  as 
shown  in  Lecture  II. 

In  other  cases  there  have  been  previous  attacks  of  renal 
colic  or  pain,  but  the  patient  has  forgotten  on  which  side  the 
pain  was  felt. 

If  under   these  circumstances   anuria   sets  in  it  mayTxT 
difficult,  or  impossible,  to  diagnose  on  which  side  the  recent 
obstruction  exists.     The  surgeon  thus  in   doubt   must   seek 
information  by  the  examination  of  the  patient  in  the  following 
manner : — 

(1)  The  course  of  the  ureter  should  be  palpated,  if 
possible,  through  the  abdominal  parietes.  This  is  often  an 
impossibility,  owing  to   the   stoutness   of  the   patient.     The 


DIAGNOSIS    OF    CALCULOUS    ANURIA.  ]09 

ureter  in  which  a  calculus  is  impacted  is  likely  to  be  in- 
flamed and  painful,  as  well  as  tender ;  even  when  a  calculus 
has  passed  along  the  ureter  it  is  likely  to  be  followed  by 
pain,  lasting  several  days  after  its  escape. 

(2)  Rectal  and  vaginal  examination  should  be  made.  In 
the  male,  digital  examination  per  rectum  has  led  to  the 
discovery  of  a  calculus  impacted  in  the  lower  part  of  the 
ureter,  as  in  Rawdon's  and  Ceci's  cases ;  in  the  female,  the 
same  discovery  has  been  made  by  vaginal  examination  by 
Emmet  and  by  myself,  and  I  have  also  detected  the  presence 
of  a  stone  by  vesical  examination  after  dilating  the  female 
urethra. 

(3)  Catheterisation  of  the  ureters,  though  easy  of  applica- 
tion in  the  female,  does  not  afford  satisfactory  assistance 
in  these  cases,  whether  done  across  the  bladder  through 
the  dilated  ureter,  or  by  vaginal  cystotomy  as  practised  "by 
Bozemann  and  Emmet,  or  by  the  aid  of  supra-pubic  cys- 
totomy. The  cystoscope  in  the  cases  of  anuria  is  quite 
unnecessary  and  out  of  place,  as  it  can  give  no  information 
which  is  not  more  fully  ascertained  by  rectal  or  vaginal 
examination  and  a  sound  in  the  bladder.  Valuable  time 
will  be  lost  by  such  explorations  of  the  ureter,  and  it 
will  be  far  better  at  once  to  resort  to  exploration  of  the 
kidney. 

If  there  be  a  calculus  in  the  terminal  part  of  the  ureter 
it  will  almost  certainly,  if  of  any  size,  be  detected  by  either 
rectal  or  vaginal  examination,  and  can  be  extracted  by  one  of 
the  operations  to  be  mentioned  later  on.  But  if  by  these  modes 
of  examination  nothing  is  detected  in  the  inferior  extremity 
of  the  ureter,  we  ought  without  delay  to  explore  one  or  both 
of  the  kidneys  through  the  loin,  and  to  select  first  the  side 
on  which  recent  pain,  or  tenderness  or  swelling,  or  a  hard 
contracted  condition  of  the  abdominal  walls  exists,  or  has 
recently  existed.  Through  such  an  incision  the  kidney  and 
adjacent  part  of  the  ureter  can  be  seen  and  felt,  and  the  rest 
of  the  ureter  catheterised ;  and  if  a  stone  be  found  it  will  be 
possible  to  remove  it,  and  if  no  stone  be  found  then  by  esta- 
blishing a  renal  fistula  relief  will  be  given  to  the  congested 
state  of  the  kidney,  and  a  condition  will  thereby  be  brought 
about  favourable  to  the  resumption  of  the  secretion  of  urine, 


110  HUNTERIAN  LECTURES. 

Calculous  anuria  and  ureemia  have  to  be  diagnosed  from 
non-obstructive  forms  of  anuria,  and  from  other  forms  of 
obstructive  disease. 

The  anuria  occurring  with  cancer  of  the  uterus  (the  most 
frequent  cause,  after  calculus,  of  obstructive  anuria) ;  and  the 
anuria  caused  by  rare  varieties  of  tumour  of  the  bladder, 
or  ureters  ;  by  uterine  myomata ;  and,  in  exceptional  cases, 
by  the  gravid  .retrofiexed  uterus,  is  alike  in  some  respects  to 
calculous  anuria ;  but  differs  very  markedly  in  others,  and 
especially  in  the  development  of  hydronephrosis  so  common 
in  cancer  and  these  other  cases,  but  so  uncommon  in  anuria 
from  calculus. 

From  'polycystic  disease. — A  case  of  anuria  from  double 
polycystic  disease,  in  which  the  symptoms  and  history  were 
those  of  calculous  obstruction,  has  been  under  my  care  this 
week.  The  patient,  a  rather  stout  but  well-made,  muscular 
man,  aged  fifty,  first  had  pain  in  his  right  loin  in  1884. 
Subsequently  he  frequently  passed  gravel,  and  in  1894,  after 
attacks  of  pain  in  the  right  kidney,  a  small  stone.  He  has 
been  in  very  indifferent  health  since  then,  suffering  pain  in 
the  right  loin.  On  Wednesday,  March  16th,  he  had  another 
attack  of  pain  like  the  former  ones,  but  in  the  left  side 
as  well  as  the  right,  and  passed  very  little  urine  after 
then.  Both  his  kidneys  were  cut  down  upon,  first  the  left, 
then,  two  days  later,  the  right.  Both  kidneys  were  found  in 
the  same  state.  Several  cysts  were  opened  in  each,  and  the 
lessened  tension  resulting  therefrom  gave  him  some  relief. 
He  died  yesterday,  March  24th,  on  the  ninth  day  of  the 
attack,  and  after  five  days  of  complete  suppression.  Muscular 
twitchings,  meteorism,  sleeplessness,  restlessness,  a  small 
rapid  pulse,  pallor  of  face,  blueness,  and  coldness  of  extremi- 
ties, and  at  last  subnormal  temperature  and  dyspnoea  were_ 
the  chief  symptoms.  The  kidneys  and  liver,  which  are  also 
cystic,  are  before  you.  There  was  no  stone  or  other  gross 
obstruction  present  throughout  the  urinary  organs. 

From  uterine  cancer. — Cancer  of  the  uterus  after  calculus 
is  the  most  frequent  cause  of  obstructive  anuria. 

I  have  seen  many  cases  of  anuria  from  uterine  cancer 
in  the  cancer  wards  of  the  Middlesex  Hospital ;  but  I  do 
not  remember  ever  to  have  seen  urcvmia  from   this  cause 


DIAGNOSIS    OF    CALCULOUS    ANURIA.  Ill 

arise  before  any  of  trie  ordinary  symptoms  of  carcinoma  of  the 
uterus  have  declared  themselves.  Such  cases,  however,  have 
been  recorded  and  have  given  rise  to  difficulty  in  diagnosis, 
as  the  suddenness  of  the  attack  has  suggested  calculous 
anuria.  Avan  reported  a  fatal  case  of  uraemia  attended  by 
eclampsia  and  prolonged  coma  in  a  woman  who  had  never 
complained  of  any  of  the  symptoms  of  uterine  cancer,  and 
who  was  suddenly  seized  with  eclampsia  in  the  street  and 
died.  Cancer  of  the  uterus  was  found  on  post-mortem 
examination  to  have  caused  double  hydronephrosis  by 
pressure  on  the  ureters. 

Complete  and  prolonged  suppression  of  urine  at  an  early 
period  of  the  cancer,  or  in  uterine  cancer  which  has  been 
latent  up  to  the  onset  of  the  anuria,  is  also  recorded.  Merklen 
quotes  cases  of  total  suppression  for  seventeen  and  twenty- 
one  days  due  to  uterine  carcinoma,  which  had  not  previously 
caused  any  of  the  classical  symptoms  of  the  disease.  Roberts 
also  cites  a  case  of  the  same  kind,  in  which  anuria  lasted 
fifteen  days,  and  presented  the  clinical  symptoms  and 
followed  the  course  of  calculous  anuria.  Such  cases  are 
very  prone  to  be  mistaken  for  anuria  from  impacted 
calculus. 

Primary  cancer  of  the  bladder  may  obstruct  the  ureters, 
like  uterine  cancer  when  it  has  invaded  the  trigone.  Roberts 
records  a  case  in  which  the  symptoms  were  those  of  calculous 
anuria ;  but  at  the  post-mortem  examination  scirrhous  car- 
cinoma at  the  base  of  the  bladder  was  found,  involving  the 
prostate  gland,  and  both  ureters  passed  for  the  length  of 
an  inch  through  the  growth.  Double  hydronephrosis — old 
on  one  side,  recent  on  the  other — was  the  result. 

Suppression  has  been  known  to  occur  suddenly,  and  to  be 
followed  by  uraemia,  vomiting,  and  fever,  as  the  result  of 
secondary  carcinoma  in  the  renal  pelves  and  ureters. 
Voluminous  tumours  of  the  uterus  or  its  appendages  may 
obliterate  the  ureters  and  give  rise  to  suppression. 

Many  cases  after  operations  for  myoma  of  the  uterus 
succumb  to  uraemia  with  dilatation  of  the  ureters  and  renal 
pelves. 

The  diagnosis  between  calculous  anuria  and  cases  of 
anuria  from  uterine  cancer,  and  the  other  causes  of  ureteral 


112  HUNTE11IAN  LECTURES. 

obstruction,  will   be   assisted   by  digital  examination  of  the 
vagina  and  rectum,  and  by  palpation  of  the  abdomen. 

Amyloid  degeneration  is  attended  commonly  by  polyuria, 
albuminuria  and  paraglobinuria ;  oedema  is  frequent,  diarrhoea 
common,  and  vomiting  and  ursemia  rare.  The  course  is  one 
of  slow  progress  with  remissions.  The  duration  of  the 
symptoms  is  considerable.  When  ursernia  occurs  in  amyloid 
degeneration,  as  it  does  in  some  cases  towards  the  end,  the 
symptoms  which  I  have  observed  are  great  restlessness  and 
sleeplessness,  delirium  approaching  the  noisy  form,  contracted 
pupils,  marked  muscular  twitchings,  diarrhoea,  diminishing 
quantity  of  urine,  with  loathing  of  food  and  loss  of  control 
of  the  sphincters.  Just  preceding  death,  the  patient  becomes 
quieter  and  coma  supervenes. 

From  traumatic  anuria. — Calculous  anuria  will  be  dia- 
gnosed from  traumatic  anuria,  in  which  the  vessels  of  both 
kidneys  are  thrombosed,  by  the  symptoms  following  an  injury  ; 
and  from  the  anuria  following  catheterisation  and  other  opera- 
tions on  the  lower  urinary  passages,  by  the  absence  of  the 
general  malaise  at  the  onset,  and  of  the  rigors,  high  tempera- 
ture, and  intense  prostration  which  accompany  urinary 
fever.  After  extensive  thrombosis  of  the  vessels,  arteries, 
or  veins  of  both  kidneys  polyuria  has  been  observed,  as  in 
the  case  recorded  by  Moxon  in  the  14th  volume  of  the  Guy's 
Reports. 

In  connection  with  the  diagnosis  of  calculous  anuria,  and 
indeed,  with  the  diagnosis  of  renal  calculus  generally,  reference 
ought  to  be  made  to  the  case  recorded  by  Mr.  Howard  Marsh, 
already  referred  to  in  Lecture  II.  (p.  52)  (Chir.  Soc.  Trans., 
vol.  xxv,,  p.  195).  Mr.  Marsh  argues  in  favour  of  Raynaud's 
disease — as  explaining  the  severe  paroxysmal  renal  colic,  the 
hsematuria,  and  the  frequently  repeated  attacks  of  anuria-lG* — 
periods  varying  from  fifteen  to  fifty  hours  at  a  time.  He 
brings  forward  many  points  in  support  of  his  argument,  and 
has  certainly  raised  a  question  of  deep  interest,  which  merits 
further  investigation. 

But  whether  the  case  in  point  is  an  instance  of  what 
might  be  called  Raynaud's  disease  of  the  kidney  or  not,  it 
presents  clinical  features  which  mark  it  off  sharply .  from 
the    class    of    calculous    anuria.       (1)    The    pain    was    too 


TREATMENT  OF  CALCULOUS   ANURIA.  113 

paroxysmal  in  character,  and  the  suppression  of  urine 
was  more  like  the  dysuria  of  renal  colic — coming  on 
and  passing  off  with  the  pain;  (2)  every  attack  of  anuria 
was  attended  by  pain,  and  other  severe  functional  and 
constitutional  symptoms,  such  as  fainting,  vomiting, 
great  headache,  and  high  temperature ;  (3)  when  the 
attacks  of  suppression  ceased,  the  urine  was  of  normal 
specific  gravity  and  often  loaded  with  blood ;  and  was 
passed  with  pain  and  difficulty.  These  symptoms  are 
quite  different  from  those  which  characterise  calculous 
anuria. 

Treatment. — The  treatment  of  anuria,  up  to  fifteen  years 
ago,  was  entirely  medical.  Death  was  the  common  result. 
No  wonder ;  for  what  else  could  be  expected  from  purgatives 
and  diuretics,  from  diaphoretics  and  antispasmodics,  from 
baths,  forced  exercise,  and  massage  ?  Drugs,  such  as 
digitalis  and  pilocarpine,  and  others,  which  induce  the 
elimination  of  a  considerable  quantity  of  water  from  the 
system,  remove  only  a  small  quantity  of  urea  with  the 
water,  and  thus  leave  the  blood  proportionately  more  highly 
charged  with  urea.  For  this  reason,  such  supposed  reme- 
dies ought  to  be  ordered  with  extreme  precaution  in  ob- 
structive anuria. 

The  surgical  treatment  of  calculous  anuria  is  a  question 
of  the  day,  and  one  of  the  greatest  importance.  Formerly, 
no  one  dared  to  do  more  than  suggest  operation,  though 
Rayer,  and  Gigon  in  1856,  had  strongly  recommended  it. 
It  is  only  since  nephrolithotomy  was  practised  that 
operations  have  been  performed  for  anuria,  and  there  are 
already  several  cases  which  show  the  advantage  of  well- 
timed  surgical  intervention.  At  the  present  time  the  neces- 
sity of  operating  ought  to  be  recognised,  nor  ought  opinions 
to  differ  as  to  the  period  of  intervention,  or  as  to  the  kind  of 
operation  to  be  done.  By  an  operation  the  calculus  can 
be  removed,  or  if  this  is  not  possible,  an  artificial  outlet 
can  be  established  in  the  loin. 

Nephrotomy  should  be  performed  in  the  gravest  cases  to 
prevent  death  from  uraemia  ;  in  the  slighter  and  intermittent 
cases,  to  extract  a  stone  which  may  at  any  time  produce 
complete  persistent  anuria. 


114  IITJNTERIAN  LECTURES. 

Nephrotomy  for  obstructive  anuria  is  only  a  recent  appli- 
cation of  a  long-recognised  principle  of  practice  in  other  fields 
of  surgery,  Why,  in  the  case  of  an  obstacle  in  the  ureter,  should 
we  hesitate  to  relieve  the  obstructed  kidney  ?  Is  it  not  all  the 
more  imperative  upon  us  to  do  so  when  the  obstructed 
kidney  is  the  only  one  which  is  functionally  active. 

When  the  obstructing  calculus  is  too  low  down  in  the 
ureter  to  be  removed  through  a  lumbar  wound,  the  parietal 
incision  should  be  prolonged  towards  Poupart's  ligament, 
the  peritoneum  should  be  detached  and  turned  inwards 
towards  the  median  line,  and  the  stone  cut  upon  through 
the  ureteral  wall,  and  extracted. 

When  the  calculus  is  in  the  lower  portion  of  the  ureter, 
or  within  or  close  to  the  vesical  orifice,  the  advisability  of 
adopting  one  of  the  special  methods  for  reaching  the  ureter 
in  these  parts  will  have  to  be  considered ;  but  in  many  cases 
the  state  of  the  patient  will  make  it  necessary  to  postpone 
this  for  a  time  at  least.  Should  the  obstruction  not  be 
removed  at  the  primary  operation,  a  lumbar  renal  fistula 
should  be  established ;  and  ureterotomy  may  be  subse- 
quently successful,  or  the  stone  may  be  naturally  expelled, 
and  thus  the  normal  channel  will  be  opened  up,  and  the 
fistula  allowed  to  close. 

Opinions  have  hitherto  differed  as  to  the  precise  time 
when  the  surgeon  should  interfere.  To  be  successful  it  is 
certain  that  the  operation  should  be  done  early  and  before 
the  ursemic  stage  is  reached.  But  since  this  stage  is 
generally  delayed  till  after  the  sixth  day,  some  authors 
have  advocated  the  fifth  or  sixth  day  as  the  period  of 
surgical  operation. 

In  Demon's  case  the  intervention  was  made  on  the  eleventh 
day,  and  in  Chevalier's  on  the  fourteenth  with  complete 
success — but  on  the  other  hand  operations  on  the  third  day 
have  been  unsuccessful  in  restoring  the  secretory  function. 
Moreover  eclampsia,  necessitating  immediate  operation,  may 
occur  as  early  as  the  third  or  fourth  day  of  the  anuria,  as  in 
Vailhen's  case.  Sudden  death  may  occur  early  in  an  anuric 
person  who  seems  to  be  in  fair  general  health. 

My  opinion  is  that  an  operation  ought  to  be  performed 
as   soon   as   the   anuria  is  established  and  the   diagnosis   is 


TREATMENT  OF  CALCULOUS  ANURIA.  115 

satisfactorily  made.  So  useless  is  medicinal  and  expectant 
treatment,  that  I  have  refused  to  attend  consultations  in 
cases  of  calculous  anuria  unless  I  have  permission  before- 
hand  to  operate  at  once  if  I  think  the  case  suitable. 

The  operation  is  serious  only  on  account  of  the  condition 
for  which  it  is  performed — viz.  (1)  the  urinary  suppression 
produced  by  the  obstruction,  (2)  the  poisoned  condition 
of  the1  blood  produced  by  the  suppression,  and  (3)  the 
structural  changes  in  the  kidney  the  consequences  of  the 
obstruction. 

We  should  operate  on  the  side  last  affected,  when  the 
indication  on  this  point  is  clear.  It  is  not  the  kidney  which 
has  longest  suffered,  or  which  has  yielded  most  calculi,  which 
ought  to  be  incised.  The  contrary  ought  to  be  the  rule, 
because  the  more  the  kidney  is  affected,  the  more  extreme  its 
degeneration,  the  less  the  secretion  which  it  will  yield,  and 
consequently  the  less  the  benefit  from  nephrotomy. 

In  the  absence  of  exact  history,  drawn  from  the  patient 
himself,  it  is  necessary  to  try  and  ascertain  by  careful  ex- 
amination of  the  abdomen  which  kidney  to  explore.  When 
there  is  no  enlargement  of  the  kidney,  and  no  pain  or  tender- 
ness, there  may  yet  be  a  considerable  degree  of  hardening 
from  contraction  of  the  abdominal  muscles  over  the  part  of 
the  kidney  which  is  last  involved. 

In  most  cases  it  will  be  best  to  explore  the  kidney  first, 
but  in  certain  exceptional  instances,  as  when  the  stone  can  be 
felt  per  rectum  or  per  vaginam,  or  evidence  clearly  points  to 
the  side  and  precise  spot  at  which  it  is  impacted,  uretero- 
tomy should  be  done.  For  this,  nothing  less  than  actually 
feeling  the  stone  through  the  abdominal  parietes  (a  most 
unlikely  thing  in  persons  suffering  from  calculous  anuria) 
ought  to  satisfy.  The  localisation  of  stone,  as  to  whether 
it  be  in  the  kidney  or  ureter,  is  very  uncertain ;  most 
frequently,  when  impacted  in  the  ureter,  the  symptoms 
it  causes  are  referred  to  the  corresponding  kidney;  but 
occasionally  the  reverse  obtains,  and  a  stone  in  the  renal 
pelvis  gives  rise  to  fixed  abiding  pain  and  acute  tenderness 
at  one  particular  spot  in  the  course  of  the  ureter. 

The  nature  of  the  operation  performed  in  the  49  collected 
cases  was  as  follows  : — 


116  HUNTERIAN   LECTURES. 

1.  Operation  stated  as  nephrotomy,  or  (in  a  few  cases) 
merely  exploration  of  kidney,  in  34  cases.  In  one  of  them 
the  operation  was  performed  by  the  thermo-cautery. 

2.  Incision  of  the  renal  pelvis,  five  cases.  One  was  done 
by  thermo-cautery. 

3.  Incision  of  the  ureter,  seven  cases.  One  was  per- 
formed through  the  rectum.  In  one  case,  not  included  in 
Table  IX.,  an  attempt  was  made  to  remove  an  obstruction 
from  the  lower  end  of  the  ureter  by  means  of  the  finger  in 
the  bladder. 

THE   TECHNIQUE   OF   THE   OPERATION    FOR   EXPLORING   THE 
KIDNEY   AND    URETER. 

The  method  I  adopt  for  exploring  the  kidney  and  ureter 
for  stone  is  the  following. 

In  the  first  place,  if  there  is  the  least  reason  for  thinking  a 
stone  has  descended  along  the  ureter,  I  make  a  digital  ex- 
amination of  the  rectum  and  sound  the  bladder  under  an 
anaesthetic.  With  the  finger  of  the  left  hand  in  the  rectum 
well  pressed  against  the  base  of  the  bladder,  I  pass  the 
beak  of  the  sound  across  the  vesical  orifices  of  the  ureters. 
In  the  female  a  similar  examining  is  made  of  the  vagina  and 
bladder;  and,  if  necessary,  the  urethra  is  dilated  and  the 
interior  of  the  bladder  is  digitally  examined,  and  inspected  by 
means  of  Kelly's  tubes  and  the  electric  light,  and  the  ureters 
are  catheterised  from  the  bladder.  But  this  inspection  is  rarely 
needful  or  helpful,  and  as  a  rule  an  unnecessary  waste  of  time. 
The  kidney  to  be  first  explored  should  be  that  on  the  side  of  the 
pain.  This  should  be  a  rule  of  practice.  Though  it  is  true,  as 
I  have  shown  in  the  second  lecture,  that  relief  of  symptoms 
(pain,  fever,  nervous  disturbance,  etc.)  may  coincidentally  follow" 
the  extraction  of  a  calculus  from  the  opposite  organ,  still  this 
is  no  proof  that  the  kidney  or  ureter  on  the  side  complained 
of  is  not  the  one  in  which  the  exciting  cause  of  the  symptoms 
is  present. 

The  incision  I  have  from  the  first  always  employed  is  a  very 
oblique  lumbar  one,  commencing  an  inch  above  and  in  front 
of  the  anterior  superior  iliac  spine,  and  continued  outwards  and 
backwards  to  the  outer  edge  of  the  erector  spinse  muscle,  about 


OPERATIONS   ON   THE  KIDNEY  AND    URETER.       117 

a  finger's  breadth  below  the  last  rib  (Fig.  24).  The  length  of  the 
incision  varies  with  the  figure  and  degree  of  stoutness  of  the 
individual.  More  frequently  than  not  it  is  unnecessary  to  begin 
so  far  forward ;  and  sometimes  it  is  advantageous  to  continue 
the  skin  incision  backwards  a  little  over  the  erector  spinse 


Fur.  24.^ 


-Showing  line  of  incision  in  Case  for  retroperitoneal  exploration  or 
excision  of  the  kidney  and  ureter. 


muscle.  The  direction  of  the  lumbar  incision  is,  however, 
always  in  a  line  between  the  points  mentioned.  When  more 
room  is  required,  a  short  vertical  or  slightly  curved  incision  is 
made  upwards  from  the  oblique  wound,  extending  over  the  back 
of  the  twelfth  rib.  This  greatly  facilitates  deep  manipulation, 
and  is  a  step  towards  clearing  the  last  rib  in  the  event  of  the  ex- 
cision of  that  bone  being  requisite.  Manipulation  is  also  some- 
times facilitated  by  snicking  the  outer  edge  of  the  quadratus 


118  HTJNTERIAN  LECTURES. 

lumborum,  and  even  that  of  the  erector  spinas.  The  latter 
very  rarely  needs  to  be  interfered  with,  and  if  divided  should 
be  sutured  at  the  end  of  the  operation. 

When  more  room  in  front  is  required  either  for  freeing* 
or  inspecting  the  kidney,  controlling  bleeding  in  the  deep 
part  of  the  wound,  or  for  tracing  the  ureter,  the  incision 
should  be  carried  in  a  curvilinear  way  toward  Poupart's 
ligament,  and  then  forward  parallel  to  and  an  inch  above  that 
ligament,  as  far  as  the  internal  abdominal  ring,  or  further. 
Bleeding  points  should  be  controlled  as  they  occur  by  torsi 
pressure  forceps,  and  if  the  last  dorsal  or  the  ilio-hypogastric 
nerve  is  in  the  way,  it  is  best  to  excise  an  inch  or  more  of  it. 
After  the  division  of  the  transversalis  fascia,  a  look  out 
should  be  kept  for  the  colon,  which  frequently  bulges  into 
the  wound  and  requires  to  be  held  aside  by  a  broad  retractor. 
With  the  forefinger,  the  back  of.  the  kidney  should  now  be 
felt,  covered  by  its  loose  fibro-cellular  investment.  By  means 
of  two  pairs  of  long  forceps  this  investment  is  seized  and 
dragged  up  into  the  wound,  and  divided  with  scissors  between 
the  forceps.  Then  at  once  bulges  out,  through  the  little 
opening,  the  fine  canary-yellow  fat  which  immediately  invests 
the  kidney.  Into  this  opening  in  the  thin  fibro-cellular  in- 
vestment the  tip  of  first  one,  then  of  the  other,  index  fingers 
should  be  inserted,  and  it  and  the  included  fat  should  be  torn 
open  and  carefully  detached  from  the  kidney.  The  renal 
pelvis  and  upper  end  of  the  ureter  should  be  palpated  before 
the  kidney  has  been  much  disturbed  from  its  position,  in 
order  to  search  for  any  small  calculus,  and,  if  one  be  present, 
to  prevent  it  from  dropping  into  the  ureter  during  the  act  of 
drawing  the  kidney  on  to  the  surface  of  the  loin.  When  freed 
of  its  connections  anteriorly,  posteriorly,  and  at  both  its 
ends,  the  kidney  should  be  brought  bodily  on  to  the  surface 
of  the  loin.  This  in  a  large  number  of  persons  can  be  done 
without  difficulty  and  without  causing  tension  of  the  renal 
pedicle ;  but  in  others,  with  thick-set  trunk  and  very  fat 
parietes,  it  is  not  possible  to  bring  the  kidney  quite  out 
of  the  body  even  when  great  traction  is  made  upon  the 
pedicle.  Forcible  pulling  upon  the  pedicle,  however,  must 
be  avoided.  When,  owing  to  these  conditions,  the  kidney 
cannot   be   brought  out   of  the   wound,  the   wound   should 


OPERATIONS   ON  THE  KIDNEY  AND    URETER.       139 

be  made  amply  large  enough  to  allow  the  surgeon  to  see 
clearly  the  kidney  which  he  is  about  to  incise.  Unless 
this  be  done,  there  is  always  the  risk  of  wounding  the  branch 
of  the  renal  artery  or  vein  which  runs  over  the  back  of  the 
renal  pelvis  before  entering  the  parenchyma  on  the  posterior 
surface  of  the  orofan.  Moreover,  small  branches  of  the  renal 
artery  anastomising  with  the  lumbar  vessels  may  be  wounded, 
and  should  be  seen  to  be  ligatured.  If  no  calculus  is  felt,  an 
incision  is  next  made  into  the  kidney  along  its  convex  border, 
whilst  the  finger  and  thumb  of  the  left  hand  steady  the 
kidney  and  compress  the  pedicle.  This  compression  of  the 
pedicle  serves  a  double  purpose :  (1)  it  limits  hemorrhage, 
and  (2)  it  prevents  a  small  calculus,  which  might  drop  out  of 
one  of  the  calyces,  from  falling  into  the  ureter.  Through 
the  wound  in  the  kidney  the  right  index  finger  is  intro- 
duced, and  a  careful  detailed  manipulation  is  made  of  every 
part  of  the  interior  of  the  organ.  Needling  the  kidney 
for  diagnostic  purposes  is  most  unreliable  and  should  be 
abandoned. 

Whether  or  not  a  calculus  be  found  in  the  kidney,  the 
ureter  should  always  be  catheterised  from  end  to  end,  to  test 
if  its  lumen  is  quite  free.  If  this  is  not  done,  a  small  calculus 
— say,  of  one  and  a  half,  or  two  grains  or  more  in  weight — 
may  be  missed. 

If  the  ureteral  catheter  can  be  passed  readily  through 
the  renal  cavity  by  way  of  the  incision  in  the  convex  border  of 
the  kidney,  this  should  be  done  ;  but  it  is  often  impossible  or 
troublesome  to  hit  off  the  orifice  of  the  ureter  in  this  way. 
If  so,  the  back  of  the  infundibulum  should  be  cleared,  and  a 
minute  longitudinal  incision  (to  be  subsequently  closed  by  a 
Lembert  suture  of  fine  silk),  should  be  made  into  it  with  the 
point  of  a  narrow  sharp  scalpel,  or  sharp-pointed  scissors,  and 
through  this  incision  the  catheter  should  be  conducted. 
(See  Fig.  4,  p.  20.)  In  doing  this,  care  must  be  used  not  to 
mistake  the  renal  vein,  or  a  branch  of  the  vein,  for  the  renal 
pelvis.  Should  such  an  error  be  made,  bleeding  will  be 
readily  controlled  by  pinching  up  the  edges  of  the  tiny 
wound,  and  applying  a  circular  ligature.  When  any  doubt 
arises,  the  vein  will  be  distinguished  from  the  ureter  by  the 
return  of  blood  into  it  after  ceasing  to  compress  the  tube. 


120 


HTJNTERIAN  LECTURES. 


There  is  often  quite  a  plexus  of  fine  blood-vessels  on  the 
surface  of  the  infundibulum  and  ureteral  wall  which  must 
be  avoided  if  possible. 


Fig.  25. — Base  of  bladder  with  stone  impacted  in  ureter  immediately  above  it. 
[Westminster  Hospital  Museum,  No.  834.) 


Fig.  26. — Sacculated  kidney  caused  by  calculus  impacted  in  lower  end  of  ureter. 
From  same  subject  as  Fig.  25.     (Westminster  Hospital  Museum,  No.  820.) 

If  there  be  a  stone  in  the  ureter,  the  catheter  Avill   be 
obstructed  at  the  point  of  impaction.     In  the  male,  whether 


OPERATIONS   ON  THE  KIDNEY  AND    URETER,      121 

this  point  be  in  the  abdominal  or  the  pelvic  course  of  the 
ureter,  the  calculus  can  be  reached  and  removed  retroperi- 
toneally,  by  prolonging  the  anterior  or  lower  end  of  the 
incision  in  the  direction  mentioned  before. 

In  the  female  the  same  procedure  answers  for  the  ab- 
dominal and  first  portion  of  the  pelvic  course  of  the  ureter ; 
but  for  the  removal  of  a  calculus  from  the  ureter  within  the 
broad  ligament,  especially  near  the  uterus  or  vagina,  the 
vaginal  or  sacral  route  is  the  best.  If  situated  quite  at 
the  vesical  orifice  of  the  ureter,  it  can  be  extracted  through 
the  bladder  after  dilating  the  urethra  and,  if  needful,  slightly 
incising  the  ureteral  orifice.  No  attempt  should  be  made 
to  extract  a  calculus  through  the  bladder  unless  it  be  situated 
quite  at  the  internal  opening.  A  calculus,  if  it  is  of  fair 
size,  may  be  felt  through  the  bladder,  when  it  is  in  the  ureter 
just  above  the  point  where  the  duct  enters  the  vesical  wall 
(see  Fig.  25).  When  here,  it  cannot  be  so  removed  without 
exposing  the  patient  to  the  danger  of  an  intraperitoneal 
urinary  fistula. 

In  a  case  recorded  by  Thornton  of  uretero-lithotomy 
this  accident  happened,  and  the  patient  died. 

In  the  male  the  sacral  method  might  also  be  employed 
for  a  stone  situated  just  above  the  bladder ;  but  the  retroperi- 
toneal inguinal  route  through  which  it  is  possible  to  trace 
the  ureter  quite  up  to  the  point  where  it  enters  the  vesical 
wall,  is  to  be  preferred. 

When  the  part  of  the  ureter  in  which  the  calculus  is 
situated  has  been  reached,  the  wall  of  the  ureter  should  be 
divided  by  a  short  longitudinal  incision  made  either  upon  the 
calculus  or  immediately  above  it.  The  calculus  should  then 
be  extruded  through  this  opening.  If  the  stone  is  impacted 
below  the  brim  of  the  pelvis  it  should,  if  possible,  be  made  to 
retrace  its  steps,  by  gentle  pressure,  till  it  is  brought  up  into 
the  duct  above  the  pelvic  brim.  If  the  ureter  is  dilated  above 
the  stone,  and  the  stone  can  be  readily  pushed  back  into  the 
dilated  portion,  this  should  be  done,  whether  the  point  of  im- 
paction is  above  or  below  the  brim  of  the  pelvis.  The  incision 
in  the  dilated  tube  may  then  be  closed  by  one  or  two 
Lembert  sutures  passed  across  the  line  of  the  incision. 
Otherwise  the  stone  must  be  directly  cut  upon  where  it  is 


122  HUNTERIAN  LECTURES. 

impacted,  and  as  the  tissues  of  the  ureter  are  likely  to  be 
much  contused,  perhaps  ulcerated,  owing  to  the  pressure  of 
the  calculus,  they  may  not  be  in  a  favourable  state  for 
immediate  repair,  and  therefore  sutures  for  the  ureteral  wound 
may  be  of  very  doubtful  utility,  or  even  harmful.  Care  should 
be  taken  to  provide  drainage  for  any  urine  which  may  escape 
through  the  ureteral  wound,  otherwise  serious  mischief  in  the 
pelvic  cellular  tissue  may  occur  from  the  too  early  closure 
of  the  external  wound,  as  happened  in  a  case  referred  to 
in  Lecture  II. 

In  the  greater  number  of  cases,  when  the  calculus 
is  not  in  the  kidney,  it  is  in  the  ureter,  within  an  inch 
or  two  of  the  infundibulum.  In  several  cases  I  have 
pressed  a  stone  upwards  out  of  the  ureter,  and  re- 
moved it  through  an  incision  in  the  wall  of  the  renal 
pelvis. 

It  is,  I  think,  quite  immaterial  whether  a  calculus  is 
removed  through  the  parenchyma  or  infundibulum  of  the 
kidney.  I  formerly  was  of  opinion  that  there  was  less  chance 
of  urine  escaping,  and  quicker  healing  of  the  wound,  when  the 
incision  involved  the  parenchyma  only.  But  since  employ- 
ing sutures,  which  I  began  to  do  several  years  ago,  I  do  not 
find  that  wounds  in  the  renal  pelvis  or  ureter  heal  any  the 
less  readily. 

In  operating  upon  the  sound  kidney,  I  do  not  hesitate  to 
cut  directly  down  upon  a  calculus,  wherever  it  may  present ; 
still  less  need  one  do  so  in  a  kidney  the  cavity  of  which  is 
pouched  and  the  parenchyma  atrophied.  When  so  made, 
the  incision  should  preferably  radiate  from  the  hilum  :  but 
when  the  parenchyma  is  very  thin,  and  a  large  branched 
calculus  or  several  calculi  are  present,  the  incision  may  be 
made  in  any  direction  which  gives  the  greatest  facility—for— 
extracting  the  stones. 

In  calculous  pyonephrosis  I  have  removed  seven  stones 
through  as  many  separate  incisions  in  the  thin  paren- 
chyma. 

After  the  removal  of  the  calculus,  the  rest  of  the 
kidney  can  be  explored  through  this  incision  ;  or,  if  not,  a 
second  incision  should  be  made  in  the  convex  border  of 
the  organ. 


OPERATIONS   ON   TEE   KIDNEY  AND    URETER.      123 

As  long  ago  as  1829  Gerdy*  had  advised  that  the  convex 
border  of  the  kidney  should  be  selected  for  incision  in 
nephrotomy.  The  advantages,  depending  on  the  anatomical 
arrangement  of  the  blood-vessels  within  the  kidney,  of  an 
incision  along  this  border  are  considerable.  Moreover,  through 
no  other  single  incision  can  a  complete  examination  of  the 
cavity  and  substance  of  the  kidney  be  so  conveniently  made. 


Fig.  27.— Kidney  with  uric-acid  calculus  impacted  in  its  pelvis. 
Hospital  Museum,  No.  828.) 


(Westminster 


It  is  the  opinion  of  Barthf  and  Turner  that  the  extent  of 
parenchymal  degeneration  about  nephrotomy  wounds  depends 
chiefly  on  the  size  of  the  vessels  divided  ;  and  if  this  be  so,  it 
is  a  further  reason  for  making  the  incision,  as  Gerdy  advised, 
along  the  convex  margin. 

After  removing  a  calculus  from  the  renal  pelvis,  if  the 
convex  border  has  not  been  incised,  the  interior  of  the 
kidney   should   be  palpated  either  through  the  opening,  or, 

*  Gerdy,  P.  1ST.  :    "Anatomie  des  Formes  Exterieures  du  Corps  Humain  " 
(Paris,  1829).     See  note  on  page  153. 

t  Arehiv  f.  klin.  Chir.,  Von  Langenbeck,  1893,  xlvi.,  418. 


124 


HUNTEIIIAN  LECTURES. 


if  this  be  too  small  to  admit  the  finger,  then  by  invaginating 
the  infundibulum. 

I  have  taken  out  some  very  large  stones,  weighing  between 
800  and  900  grains,  through  incisions  in  the  dilated  infundi- 
bulum, large  enough  to  admit  readily  the  tips  of  two  fingers. 
In  such  cases  an  incision  in  the  convexity  of  the  organ  for 
examination  purposes,  is  quite  unnecessary.  In  some  cases, 
indeed,  the  calculus  is  so  bound  down  into  the  renal  cavity 


Fig.  28. — The  same  kidney  as  shown  in  Fig.  27,  seen  from  within  to  show  an  uric-acid 
calculus  impacted  in  pelvis  and  bound  down  by  dense  fibrous  bands.  ( Westminster 
Hospital  Museum,  No.  828.) 


by  thick  fibrous  bands  between  the  calyces  that  its  extraction 
would   be  most   difficult   through   an   incision   in   the  feTiai — 
substance,  whereas  it  is  readily  pulled  out  through  the  in- 
fundibulum.    (See  Figs.  27  and  28.) 

I  have  repeatedly  extracted  calculi  through  the  anterior  as 
well  as  through  the  posterior  wall  of  the  renal  pelvis  without 
a  drop  of  urine  subsequently  escaping  through  the  loin  wound. 
This  result  may  be  safely  expected  provided  the  renal  opening 
has  been  closed  by  Lembert  sutures  passed  transversely. 

If  sutures  are  not  used  it  is  better,  if  convenient,  to  open 


OPERATIONS   ON   THE  KIDNEY  AND    URETER.       125 

the  anterior  rather  than  the  posterior  surface,  for  it  stands  to 
reason  that  the  urine  as  it  courses  along  upon  the  posterior 
wall  of  the  duct,  when  the  patient  is  recumbent,  is  less  likely 
to  escape  through  an  incision  in  the  anterior — i.e.  the  upper 
— wall  of  the  passage. 

In  advanced  pyonephrosis  I  have  not  always  used  sutures 
after  nephrotomy,  and  it  has  often  been  a  matter  of  surprise 
how  readily  some  of  these  cases  recover  without  having  even 
a  temporary  urinary  fistula.  Suppuration  in  the  renal  cavity 
is  by  no  means  always  a  sufficient  reason  for  not  using  sutures 
and  for  not  making  an  attempt  to  obtain  immediate  union. 

Fenger,  whose  opinion  in  renal  surgery  commands  atten- 
tion, does  not  believe  that  a  kidney  with  a  stone  in  its  pelvis 
is,  in  any  case,  really  aseptic,  and  he  warns  against  the 
employment  of  sutures,  or  making  an  attempt  to  secure 
primary  union.  He  relates  a  case  in  support  of  this  con- 
tention ;  but  neither  the  case  nor  the  arguments  are  con- 
vincing. 

When  the  renal  cavity  is  sacculated  and  suppurating,  it 
should  be  freely  irrigated  with  a  hot,  weak  solution  of  Condy's 
fluid,  of  per  chloride  mercury,  or  of  carbolic  acid.  In  a  few 
instances  the  calyces  have  been  found  packed  with  a  putty- 
like mass  of  muco-pus,  which  was  thoroughly  cleared  out 
with  the  finger  and  little  swabs  of  cotton-wool. 

In  every  case  a  drainage-tube  is  inserted  into  the 
wound  around  the  kidney,  but  not  into  the  kidney  cavity 
itself.  I  prefer  a  tube  to  iodoform  gauze,  for  the  latter, 
by  sucking  up  and  retaining  the  serum  and  blood,  keeps 
the  surfaces  of  the  wound  apart,  and  prevents  immediate 
healing. 

In  closing  the  parietal  wound  I  transfix  the  whole  of  the 
layers,  skin,  muscles,  and  fascise,  with  the  same  sutures 
carried  by  means  of  Hagedorn's  large  curved  needles.  I 
have  for  some  considerable  time  abandoned  the  use 
of  buried  sutures  for  the  separate  layers  of  muscles  and 
fasciae. 

The  length  of  time  required  for  convalescence  of  course 
varies.  In  cases  of  simple  nephrolithotomy  patients  are  often 
able  to  sit  up  on  the  eleventh  or  twelfth  day,  with  their  wounds 
healed ;  and  many  have  returned  to  their  houses  between  the 


126  HUXTERIAN  LECTURES. 

second  and  third  weeks  after  the  operation.  Nephrectomy  is 
frequently  as  rapidly  followed  by  complete  recovery.  When 
the  kidney  and  the  perinephric  tissues  are  much  dis- 
organised, healing  is  apt  to  take  place  for  the  most  part  by 
granulations,  and  thus  after  nephrotomy  four  or  five  weeks 
are  often  required. 


LECTURE    IV. 

INJURIES    OF     THE     URETER.* 

Injuries  to  the  ureter  are  exceptionally  rare,  if  we  exclude 
those  which  occasionally  happen  in  the  course  of  certain 
surgical  operations  on  the  abdominal  or  pelvic  viscera.  Its 
small  size,  its  deep  position,  the  fact  that  in  one-half  of  its 
extent  it  is  protected  by  the  bony  wall  of  the  pelvis,  its  loose 
connections  whereby  it  is  able  to  move  freely  upon  the  struc- 
tures behind  it,  together  with  its  own  elasticity,  serve  to  explain 
this  exemption  from  injury. 

In  1885,  when  writing  on  "  Rupture  of  the  Ureter,"  I 
stated  f  there  was  no  occasion  to  consider  it  apart  from 
rupture  of  the  kidney,  because  in  the  very  few  cases  on  record 
the  rupture  of  the  ureter  was  quite  close  to  the  renal  pelvis, 
and  that  it  was  neither  practicable  nor  requisite,  from  the 
point  of  view  of  treatment,  to  distinguish  between  sub- 
cutaneous rupture  of  the  renal  pelvis  and  subcutaneous 
rupture  of  the  ureter. 

With  reference  to  "  Penetrating  Wounds  of  the  Ureter,"  I 
therein  pointed  out  that,  with  the  exception  of  the  gunshot 
wound  of  the  ureter  which  happened  to  the  Archbishop  of 
Paris  in  1848,  %  and  the  doubtful  case  recorded  by  Hennen  in 
1818,  §  there  did  not  exist  any  published  report  of  a  pene- 
trating wound  of  the  ureter  alone,  unless  we  accept  Holmes' 
very  doubtful  case  as  suchj  M.  Leon  Le  Fort  has  since 
published  a  case  of  penetrating  wound,  completely  dividing 
the  ureter  by  a  knife  (Bull,  de  VAcademie  de  Medecine, 
November  9th,  1880,  p.  1185). 

No  case  of  penetrating  wound  is  reported  to  have  occurred 
in  the  American  War  of  the  Rebellion ;  and  when  we  recall 

*  Revised,  with  additions,  and  reprinted  from  the  Edinburgh  Medical  Journal, 
January,  1898. 

+  "  Surgical  Diseases  of  the  Kidney." 

J  Gaz.  d.  hop.,  Paris,  1848. 

§  "  Military  Surgery,"  3rd  edition,  p.  430,  Case  72. 

||  Med.-Chir.  Trans.,  London,  vols,  lx,  and  lxv. 


128  INJURIES   OF   THE    URETER. 

the  care  and  thoroughness  with  which  the  medical  and 
surgical  history  of  that  war  was  prepared,  this  fact  alone 
shows  the  extreme  rarity  of  such  injury. 

The  conclusion  arrived  at  was  that  the  diagnosis,  symp- 
toms, sequelae,  and  treatment  of  injured  ureter  in  no  way 
differed  from  those  of  ruptured  or  wounded  kidney. 

These  remarks  were  based  upon  a  careful  perusal  of  the 
reports  of  thirteen  cases  described  as  subcutaneous  injuries, 
and  upon  the  three  cases  above  mentioned  of  penetrating 
wounds.  The  cases  were  all  that  I  was  at  that  time  able  to 
discover,  after  a  fairly  laborious  search  through  the  literature 
of  wounds  and  other  injuries  of  the  abdominal  viscera. 

Two  of  the  cases  of  subcutaneous  injuries  had  been  under 
my  own  personal  observation.  As  dresser  to  Mr.  Hilton,  I 
was  responsible  for  the  notes  of  his  case,  which  was  one  of 
rupture  of  the  kidney,  not,  as  Poland  described  it,  and  others 
have  quoted  it  as  being,  one  of  rupture  of  the  ureter ;  and, 
as  house  surgeon  at  Guy's  Hospital  at  the  time,  I  daily 
watched  Mr.  Poland's  case,  which  was  really  one  of  ruptured 
ureter. 

Although  reports  of  renal  cases  of  a  surgical  nature  have 
during  the  last  ten  years  multiplied  a  thousandfold,  and 
although  experimental  researches  and  tried  or  suggested 
operations  upon  the  ureter  have  led  to  the  surgical  affections 
of  the  ureter  being  considered  as  a  subject  distinct  from  the 
surgical  affections  of  the  kidney,  there  is  very  little  as  yet 
which  can  strictly  be  called  ureteral  surgery ;  and  very  few 
cases  have  been  published  which  are  really  cases  of  unmixed 
ureteral  disease  or  injury. 

Since  1885,  only  seven  cases,  so  far  as  I  am  aware,  have 
been  published,  purporting  to  be  subcutaneous  injuries  of  the 
ureter — namely,  by  Godlee,  1887;  Chaput,  1889;  Le  Deirtuj- 
1889 ;  Coull  Mackenzie,  1891  ;  Allingham,  1891 ;  Fenger, 
1894;  Page,  1894.  These  are  not,  however,  all  cases  of 
injury  to  the  ureter  proper,  and  they  do  not  supply  any 
grounds  for  altering  the  conclusions  based  upon  earlier  cases. 

In  view,  however,  of  the  growing  importance  attached  to 
the  surgery  of  the  ureter,  it  is  well  to  describe  the  injuries  of 
the  ureter,  and  the  operations  performed  and  suggested  for 
their  relief,  apart  from  those  relating  to  the  kidney. 


INJURIES   OF   THE    URETER.  129 

The  injuries  involving  the  ureter  depend  very  much  as  to 
their  symptoms  and  gravity  upon  whether  they  are  sub- 
cutaneous or  open,  extra-  or  intraperitoneal.  They  may  be 
conveniently  considered  under  three  classes  : — 

(1)  Subparietal  injuries  ;  or  those  in  which  no  open  wound 
communicates  with  the  injured  ureter. 

(2)  Penetrating  wounds  ;  or  those  in  which  an  open  wound 
communicates  with  the  injured  ureter. 

(3)  Surgical  wounds,  accidentally  or  intentionally  in- 
flicted, including  those  which  are  caused  by  the  use  of 
obstetric  instruments,  or  following  gangrene  due  to  difficult 
or  prolonged  labour. 

Those  which  result  from  gangrene  and  from  overlooked 
surgical  accidents  come  necessarily  for  consideration  under 
ureteral  fistula ;  whilst  those  made  intentionally  by  the 
surgeon,  and  recognised  accidental  wounds,  are  considered 
under  "  Operations  upon  the  Ureter." 

In  all  three  classes  the  peritoneum  may  or  may  not  be 
involved.  In  Class  1,  as  a  rule,  it  is  not ;  in  Class  2  it  is  most 
likely  to  be ;  whilst  in  the  accidental  wounds  of  Class  3, 
excepting  those  produced  by  obstetric  instruments  and  those 
caused  by  sloughing,  it  almost  always  is. 

In  this  article  I  shall  confine  my  remarks  to  Class  1 — 
that  is,  to  subparietal  injuries  of  the  ureter. 

Twenty-three  cases  are  now  scattered  through  surgical 
literature,  which  have  been  repeatedly  mentioned  by  writers 
as  subcutaneous  injuries  of  the  ureter  ;  but  a  close  examina- 
tion of  the  details  given  of  them  shows  that  twelve  at  least 
are  injuries  of  the  parenchyma  or  pelvis  of  the  kidney,  not  of 
the  ureter  proper,  and  there  is  considerable  room  for  doubt  as 
to  the  exact  nature  of  the  injury  in  several  of  the  others. 
The  explanation  of  the  fact  that  cases  of  ruptured  renal  pelvis 
are  so  often  described  as  ruptured  ureter  is  no  doubt  in  part 
due  to  the  want  of  uniformity  in  the  use  of  terms.  The 
ureter  in  anatomical  works  is  described  as  commencing  at  the 
renal  pelvis  ;  but  the  term  renal  pelvis  is  often  used  as  if  it 
were  synonymous  with  hilum  of  the  kidney,  instead  of  em- 
bracing that  dilated  part  of  the  renal  duct  which  extends 
from  the  union  of  the  calyces  to  the  upper  end  of  the  ureter 
proper. 


130  INJURIES   OF   THE    URETER. 

The  following  is  a  list  of  the  twenty-three  cases  to  be  found 
in  surgical  literature,  described  as  "  rupture  of  the  ureter." 
Thirteen  of  them  were  more  or  less  fully  quoted  in  my  book 
on  the  kidney  in  1885.  Seven  others  have  been  published 
since  then.  The  remaining  three  had  been  previously  over- 
looked by  me,  namely,  those  by  Joel,  Cabot,  and  Bardenheuer. 
The  whole  twenty-three  cases  are  now  arranged  in  four 
different  groups. 

(A)  Verified  cases  of  rupture  of  the  ureter — (1)  Poland 
(with  extraperitoneal  extravasation  and  tumour),  (2)  Coull 
Mackenzie  (with  intraperitoneal  extravasation,  but  no  tumour). 

(B)  Probable  rupture  of  ureter  with  extravasation — (1) 
Stanley  (boy),  (2)  Godlee,  (3)  Chaput,  (4)  Page. 

(C)  Contracted  ureter,  with  hydronephrosis,  etc.,  possibly 
due  to  ureteral  injury — (1)  Haviland,  (2)  Pye-Smith,  (3)  Soller, 
(4)  Cabot,  (5)  Fenger. 

(D)  Not  injuries  of  the  ureter  proper,  but  rupture  of  renal 
pelvis,  or  renal  substance  opening  calyces,  and  giving  rise  to 
extravasation — (1)  Stanley  (female),  (2)  Hilton,  (3)  Hicks,  (4) 
Barker,  (5)  Bardenheuer,  (6)  Dumenil,  (7)  Joel,  (8)  Allingham, 
(9)  Harrison  (two),  (10)  Croft,  (11)  Bennett  May. 

Besides  the  above,  Dr.  W.  J.  Collins*  has  published  two 
cases  of  traumatic  hydronephrosis,  in  which  the  injury  may 
have  been  either  to  the  ureter  or  to  the  renal  pelvis.  Dr. 
Collins  thought  that  the  most  plausible  explanation  of  one  of 
these  cases  was  occlusion  of  the  ureter,  from  contraction  fol- 
lowing bruising  at  the  time  the  child,  set.  5,  was  run  over ;  or 
else  compression  by  blood,  or  by  callus  thrown  out  around 
a  fracture  of  the  pelvis.  In  neither  case  was  there  any  direct 
evidence  as  to  the  cause  of  the  hydronephrosis. 

Of  the  twenty- three  cases,  we  find  only  eleven  with  any 
pretensions  to  be  considered  injuries  of  the  ureter  properTandr^ 
of  these  only  two  were  actually  proved  to  be  ruptures  of  the 
ureter.  One  of  the  two  (Coull  Mackenzie's)  was  an  undoubted 
case  of  intraperitoneal  laceration,  and  was  verified  as  such  by 
post-mortem  examination.  In  a  patient  under  m}^  care  the 
ureter  was  subsequently  ascertained  by  operation  to  have  been 
torn  away  from  the  infundibulum.  This  case  is  again  referred 
to  on  pages  144,  153,  and  154. 

*  Brit.  Med.  Joum.,  London,  April  30,  1892. 


INJURIES   OF   THE    URETER.  131 

In  five  cases  (Group  C)  atiinumr  was  formed  by  alteration 
in  the  kidney  itself.  In  four  of  these,  contraction  or  oblitera- 
tion of  the  ureter  followed  the  injury,  and  after  a  long  time  a 
renal  tumour  formed ;  in  three  of  them  the  condition  was 
ascertained  by  post-mortem  examination  to  be,  in  one,  pyo- 
nephrosis with  atrophy  and  impermeability  of  the  ureter 
(Haviland's) ;  in  another,  pyonephrosis  (which  had  at  one  time 
communicated  with  the  colon),  with  the  ureter  contracted 
1^  in.  from  its  commencement,  so  as  scarcely  to  admit  the 
smallest  probe  (Pye-Smith's) ;  and  in  the  third,  the  kidney 
was  converted  into  a  large  polycystic  tumour,  and  the  ureter 
in  the  middle  of  its  course  was  almost  obliterated  (Soller's). 
In  the  fourth  case  the  ureter  was  strictured,  and  an  intermit- 
tent hydronephrosis  developed  ten  years  after  the  injury.  The 
hydronephrosis  had  existed  for  twenty-four  years  when  Fenger 
performed  ureterotomy  from  the  loin.  He  divided  the  stric- 
ture, and  closed  the  wound  in  the  ureter  by  longitudinal 
sutures,  after  the  Heinecke-Mikulicz  method  for  the  treatment 
of  pyloric  stricture.  The  patient  recovered,  and  had  no  return 
of  the  hydronephrosis  (Fenger's).  In  the  fifth  case  (Cabot's) 
the  nature  of  the  obstruction  and  its  precise  situation  were 
not  ascertained.  It  is  described  by  Cabot  as  one  of  "  nephro- 
tomy for  hydronephrosis,"  and  resulted  in  recovery.  The 
swelling  developed  "  several  weeks  "  after  a  fall,  and  it  seems 
to  me  highly  probable  that  the  obstruction  was  only  partial 
and  temporary,  and  was  caused  by  blood  clot,  either  in  the 
renal  pelvis  or  in  the  ureter,  which  subsequently  became 
absorbed  or  passed  on  into  the  bladder. 

In  Haviland's  case  the  injury  was  received  four  years 
before  the  tumour  developed,  in  Pye-Smith's  two  years, 
in  Soller's  nine,  and  in  Fenger's  ten  years  before.  It 
is  very  doubtful  whether  the  condition  of  the  ureter  in 
Haviland's  and  Soller's  cases  was  not  due  to  causes  other 
than  injury. 

In  five  cases,  namely,  those  included  in  Group  B  and 
Poland's  case,  a  tumour  was  formed  by  a  collection  of  fluid 
behind  the  peritoneum. 

In  none  of  these  instances  was  the  precise  seat  of  the 
extravasation  ascertained.  Stanley's  case  was  that  of  a  boy  in 
many  respects  precisely  like  Croft's  and  Bennett  May's  and 


132  INJURIES   OF   THE    URETER. 

others,  where  the  injury  was  supposed  or  ascertained  to  have 
implicated  the  renal  pelvis  and  not  the  ureter. 

There  is  also  much  room  for  doubt  as  to  whether  the 
ureter  proper  was  injured  in  Godlee's  case.  It  is  more  than 
probable  that  the  injury  was  to  the  renal  pelvis,  but  that  it 
could  not  be  discovered  at  the  time  of  the  nephrotomy,  nor, 
owing  to  the  difficulty  in  separating  the  kidney  from  the  sur- 
rounding tissues,  at  the  subsequent  nephrectomy.  We  cannot, 
however,  positively  exclude  either  of  these  cases  from  the  list 
of  injuries  to  the  ureter.  The  two  other  cases  in  this  group 
(Chaput's  and  Page's)  are  in  great  probability  veritable  injuries 
to  the  ureter  proper. 

Chaput's  case  is  exceptional,  in  that  the  csecurn  was  rup- 
tured on  its  posterior  aspect,  and  the  extravasated  urine,  not 
only  accumulated  in  the  retroperitoneal  tissue,  but  entered  the 
caecum  through  the  rupture  in  its  wall,  and  distended  this 
gut  and  the  neighbouring  colon  so  as  to  create  a  very  mislead- 
ing abdominal  tumour. 

In  three  of  these  cases  (Godlee's,  Chaput's,  and  Page's),  an 
incision,  followed  by  drainage  of  the  retroperitoneal  space,  was 
practised,  and  in  Godlee's  case  evacuation  had  been  effected 
before  the  lumbar  incision  was  made.  In  each  of  these  three 
cases  nephrectomy  was  subsequently  and  successfully  resorted 
to,  because  of  pyrexial  attacks  due  to  suppuration  of  the 
kidney,  and  of  the  persistence  of  a  fistula. 

In  Page's  case  the  incision  was  made  in  the  linea  semi- 
lunaris, and  drainage  was  effected  through  this.  In  Chaput's 
case,  as  well  as  in  Godlee's,  the  incision  and  drainage  were 
through  the  loin. 

The  fifth  case,  in  which  a  tumour  formed  behind  the 
peritoneum  (Poland's),  is  allied  to  the  four  cases  just  men- 
tioned, though  it  differs  from  them  in  some  most  important 
particulars.  As  the  accident  resulted  in  death  on  the  sixth 
day,  the  exact  nature  of  the  injury  was  ascertained  by  post- 
mortem examination. 

Poland  describes  the  ureter  as  torn  quite  across,  just 
below  the  renal  pelvis ;  and  its  broken  end,  together  with  the 
kidney,  was  surrounded  by  the  half-sloughy,  putrescent,  and 
jelly-like  tissues  behind  the  peritoneum.  The  kidney  itself 
was  injured,  its  capsule  being  separated  from  it  by  extravasated 


INJURIES   OF   THE    URETER.  133 

blood ;  the  renal  capsule  prevented  this  blood  clot  from 
mixing  with  the  urine  extravasated  through  the  torn 
ureter.  The  right  lumbar  region  was  raised  in  a  great 
swelling,  this  being  moderately  dark  in  colour  from  some 
effusion  of  blood. 

It  is  unnecessary  to  analyse  the  twelve  cases  in  Group  D, 
which  have  been  often  quoted  as  subcutaneous  injuries  of  the 
ureter,  but  which  in  reality  are  not  so.  It  will  suffice  to  give 
a  list  of  these,  with  the  dates  and  references  to  them.  This  is 
done  at  the  end  of  this  article. 

We  will  now  summarise  the  result  of  a  careful  analysis  of 
the  eleven  cases  above  mentioned,  with  the  view  of  arriviug  at 
the  causes,  pathology,  symptoms,  and  treatment  of  ureteral 
subcutaneous  injuries. 

Causes. — Of  the  eleven  cases  above  enumerated,  forcible 
compression  between  two  hard  bodies,  at  the  level  of  the 
umbilicus  and  loin,  was  the  form  of  violence  inflicted  in  three; 
kicks  from  horses  in  two  (Chaput's  and  Pye-Smith's) ;  the 
passage  of  the  wheel  of  a  carriage  over  the  trunk  in  two 
(Godlee's  and  Page's) ;  falling  on  to  the  back  from  a  height  in 
one  (Haviland's) ;  falling  down  stairs  in  one  (Cabot's) ;  the 
bursting  of  a  cannon  shell  in  one  (Soller's)  ;  and  a  violent 
jerk  in  jumping  from  a  horse  in  one  (Fenger's  case).  It  is 
noteworthy  that  in  both  the  cases  in  which  the  peritoneum 
was  ruptured  (Poland's  and  Coull  Mackenzie's)  the  form  of 
violence  was  forcible  compression  of  the  trunk — between  the 
platform  and  a  railway  carriage  in  one,  and  between  two 
heavy  trucks  in  the  other. 

Turner  has  suggested  that  the  ureter  gives  way  by  being 
crushed  against  the  tip  of  the  transverse  process  of  the  first 
lumbar  vertebra.  This  may  be  the  method  by  which  the 
renal  pelvis  more  often  is  torn,  opposite  the  hilum  of  the 
kidney ;  but  the  ureter  only  commences  a  little  above  the 
level  of  the  tip  of  the  transverse  process  of  the  third  lumbar 
vertebra,  too  low  down,  therefore,  to  be  crushed  against  the 
first  transverse  process,  though  it  may  be  so  compressed 
against  the  tips  of  the  third,  fourth,  or  fifth  processes.  In 
Poland's  fatal  case,  in  which  the  ureter  at  its  junction  with 
the  renal  pelvis  was  torn  right  across,  the  transverse  processes 


134  INJURIES   OF   THE    URETER. 

of  the  three  upper  lumbar  vertebrae,  on  both  sides,  were 
broken  off,  and  the  twelfth  rib  on  each  side  was  fractured. 

Le  Dentu  thinks  a  veritable  tear  of  the  ureter  may  be 
caused  by  the  sudden  and  violent  downward  displacement  of 
the  kidney,  the  weight  of  which  drags  forcibly  upon  the 
ureter  at  its  junction  with  the  renal  pelvis,  or  at  some  point 
lower  down  than  this,  namely,  at  the  level  at  which  the  ureter 
retains,  during  the  shock,  its  normal  attachments. 

As  the  kidney  is  under  cover  of  the  lower  ribs,  and  the 
lower  half  of  the  ureter  is  protected  by  the  bones  of  the  pelvis, 
it  would  seem  that  any  great  violence,  applied  either  from  in 
front  or  from  behind,  will  tend  to  stretch  the  ureter  most 
severely  at  one  or  other  extremity  of  its  abdominal  course, 
whilst  the  intervening  portion  will  escape  with  the  rest  of  the 
soft  structures  in  the  ilio-costal  space.  The  holdfast  influence 
of  the  kidney  above,  and  the  resistance  of  the  brim  of  the 
pelvis  below,  would  thus  tend  to  the  giving  way  of  the  ureter 
at  its  junction  with  the  renal  pelvis,  or  just  above  the  place 
where  it  passes  over  the  sacro-iliac  synchondrosis. 

The  fact  that  in  five  out  of  eleven  cases  the  injury  was 
brought  about  by  violent  compression  of  the  trunk  in  the 
antero-posterior  axis,  and  in  a  sixth  case  (Fenger)  was  caused 
by  overstretching,  gives  support  to  this  theory. 

The  intimate  adhesion  of  the  ureter  to  the  peritoneum; 
the  readiness  with  which  it  becomes  detached  with  the 
peritoneum,  when  the  latter  is  torn  away  from  its  con- 
nections ;  and  the  fixation  of  the  peritoneum  to  the  spinal 
column,  make  it  probable  that  the  peritoneum  will  yield  just 
external  to  the  line  of  fixation  to  the  spine  rather  than  that 
the  ureter  will  give  way.  Possibly  this  is  what  really  happens, 
and  thus  the  ureter  escapes. 

The  fact  that  the  peritoneum  over  the  ureter  was  injured 
in  onlv  one  case  out  of  eleven,  and  that  in  five  cases  out  of 
eleven  there  was  a  large  retroperitoneal  accumulation  of 
urine,  without  the  peritoneum  giving  way,  suggests  that  in 
the  rare  instances  when  the  ureter  is  ruptured  there  is  less 
than  the  normal  adherence  between  the  ureter  and  peritoneum. 

Perhaps  this  helps  to  explain  the  greater  frequency  with 
which  subcutaneous  rupture  of  the  ureter  occurs  in  young 
life  ;  thus,  of  ten  cases  in  which  the  ages  of  the  patients  are 


INJURIES   OF  THE   URETER.  135 

given,  only  two  were  over  30,  only  one  was  between  20  and 
30,  four  were  between  4  and  10  years  of  age,  and  three  were 
between  10  and  16. 

The  ages  at  which  the  accidents  happened  were  4,  5,  9,  10, 
13,  14,  16,  22,  33,  36. 

Pathology. — The  actual  nature  of  the  injury  inflicted  on 
the  ureter  can  only  for  the  most  part  be  imagined,  because  in 
only  two  cases  has  it  been  actually  seen.  In  Poland's  patient, 
who  died  135  hours  after  the  accident,  the  ureter  was  torn 
right  across,  below  the  pelvis  of  the  kidney.  The  kidney 
itself  was  much  damaged.  In  Mackenzie's  case  there  were 
two  small  ruptures  in  the  ureter,  each  of  the  size  of  a  pea, 
communicating  with  the  peritoneal  cavity. 

In  both  these  cases  the  peritoneum  was  torn ;  but  only  in 
one  (Coull  Mackenzie's)  did  the  rent  in  the  serous  membrane 
allow  of  the  entrance  of  urine  into  the  cavity,  and  in  that 
case  death  ensued  from  peritonitis  within  twenty-four  hours 
of  the  accident.  In  Poland's  case,  the  rupture  of  the  peri- 
toneum was  on  the  anterior  wall  of  the  abdomen,  and  quite 
distinct  from  the  ureteral  injury  ;  the  patient  died  from  ex- 
haustion due  to  vomiting,  but  there  was  no  peritonitis. 

In  Mackenzie's  case,  in  which  the  whole  of  the  peritoneum 
was  described  as  being  highly  inflamed,  and  the  intestines 
matted  together  by  lymph,  it  is  to  be  regretted  that  we  have 
no  information  as  to  the  character  of  the  urine.  We  know 
the  peritoneum  is  tolerant  of  healthy  urine ;  but  it  was 
probably  the  admixture  of  blood  with  the  urine  in  the  peri- 
toneal cavity  that  caused  the  fatal  peritonitis. 

In  five  cases  (out  of  the  nine  in  which  we  have  no  precise 
definite  knowledge  of  the  exact  nature  of  the  injury  inflicted) 
it  is  necessary  to  assume  that  the  ureter  was  more  or  less 
completely  torn  across,  or  else  lacerated  in  a  longitudinal 
direction,  in  order  to  explain  the  extravasation  of  urine  into 
the  retroperitoneal  cellular  tissue.  In  those  instances  where 
the  ureter  was  found  constricted  or  obliterated,  some  loner 
time  after  an  injury,  one  of  several  things  may  have  happened. 
The  ureter  may,  in  the  first  instance,  have  been  simply  con- 
tused, or  its  wall  may  have  been  only  partly  torn  through, 
and  subsequently  have  undergone  cicatricial  contraction,  or 


136  INJURIES   OF  THE    URETER 

occlusion  ;  or  the  cellular  tissues  around  it  may  have  been 
the  seat  of  the  injury,  and  the  constriction  of  the  ureter  may 
have  been  the  consequence  of  the  subsequent  iniiammatory 
changes  in  those  tissues,  or  of  compression  by  blood  clot  on 
its  exterior ;  or,  again,  the  narrowing  may  have  been  the 
result  of  haemorrhage  from  the  kidney,  and  the  impaction  and 
subsequent  organisation  of  a  blood  clot  in  the  ureter — the 
changes  in  which,  after  a  time,  may  or  may  not  have  allowed 
of  the  passage  of  urine. 

But,  however  this  may  be,  the  inference  is  obvious,  that  if 
the  coats  of  the  ureter  are  completely  torn  through,  and  the 
peritoneum  is  intact,  a  tumour  will  sooner  or  later  be  formed 
by  the  accumulation  of  urine  in  the  retroperitoneal  tissue  ; 
whereas  if  the  ureter,  from  direct  or  indirect  injury,  becomes 
imperfectly  obliterated,  a  tumour  will  in  course  of  time  be 
formed,  consisting  of  one  or  other  of  the  varieties  of  obstructed 
kidney,  namely,  renal  abscess,  pyonephrosis,  hydronephrosis, 
or,  as  in  Soller's  case,  a  polycystic  kidney. 

If  the  ureter  were  to  be  at  once  completely  obstructed  by 
blood  clot,  and  permanently  remain  so,  the  result  to  be  ex- 
pected is  atrophy  of  the  kidney.  Yet  this  does  not  necessarily 
follow,  as  shown  by  the  post-mortem  examination  on  a  man 
set.  36,  whose  right  kidney  was  ruptured  by  the  kick  of  a 
horse.  In  this  case  (recorded  by  Mr.  Holmes)"  the  ureter, 
renal  pelvis,  and  calyces  were  found  plugged  with  blood  clot 
eighteen  months  after  the  kidney  had  been  ruptured ;  the 
clot  in  the  interior  of  the  kidney  communicated  with  a  mass 
in  the  perinephric  cellular  tissue,  and  the  line  of  rupture  could 
be  faintly  traced  through  the  substance  of  the  gland,  which 
was  quite  healed.  Both  kidneys  were  small,  granular,  and 
cystic,  and  had  probably  been  so  for  a  year  or  two  before  the 
accident.  There  was  no  marked  difference  in  the  size-ancL 
general  appearance  of  the  two  kidneys. 

In  two  of  the  eleven  cases  under  consideration,  a  com- 
munication was  formed  between  the  urine  cavity  and  the  large 
bowel ;  in  Pye-Smith's  case  the  colon  was,  at  the  post-mortem 
examination,  found  adherent  to  the  pyonephrotic  cyst,  but  the 
communication  had  become  closed.  In  Chaput's  case,  a 
rupture  of  the  posterior  wall  of  the  csecuni  allowed  of  a  com- 

*  Trans.  Path.  Soc,  London,   1860,  vol.  xi.,  p.   140. 


INJURIES   OF   THE    URETER,  137 

munication  between  the    bowel  and   a   large  retroperitoneal 
collection  of  urine. 

Symptoms. — The  manifestations  of  subcutaneous  rupture  of 
the  ureter  are  not  characteristic.  For  a  time  there  may  be  no 
sign  whatever,  beyond  the  pain  and  tenderness  caused  by  the 
injury.  It  is  only  by  the  subsequent  development  of  symptoms 
that  we  are  able  to  learn  that  any  damage  has  been  done  to 
the  urinary  system,  and  not  even  then  are  we  able  to  say  at 
once  whether  it  affects  the  renal  parenchyma,  the  renal  pelvis, 
or  the  ureter. 

There  may  be  no  immediate  indication  in  the  urine  of  any 
kind  whatever.  Hseinaturia  may  be  entirely  absent,  the  urine 
being  passed  naturally  and  freely,  as  in  Stanley's,  Godlee's. 
and  Chaput's  cases ;  or  slight  hsematuria,  of  a  more  or  less 
transient  character,  may  be  observed,  as  in  Page's  patient, 
who,  after  the  second  day,  passed  at  intervals  small  quantities 
of  blood  with  the  urine ;  or  there  may  be  well-marked 
hsematuria,  as  in  Cabot's  case,  in  which  there  was  bloody 
urine  for  three  or  four  days ;  or,  as  in  Pye-Smith's  patient, 
who  had  hsematuria  for  several  days  after  the  injury. 

If  the  ureter  alone  is  ruptured,  it  is  not  likely  that  the 
hematuria  will  be  very  considerable  or  prolonged :  though 
slight  hseinaturia,  or  even  the  absence  of  haemorrhage,  is  in  no 
way  characteristic  of  ureteral  as  distinguished  from  renal 
injury,  because  many  cases  prove  that  there  may  be  but  little, 
if  any,  blood  in  the  urine,  even  though  the  renal  pelvis  or  the 
renal  parenchyma  be  wounded. 

If,  besides  injury  to  the  ureter,  one  or  both  kidneys  are 
seriously  damaged,  there  may  be  incomplete  or  complete  sup- 
pression of  urine.  Thus,  in  Poland's  case,  there  was  throm- 
bosis of  all  the  vessels  of  the  opposite  kidney,  as  well  as  severe 
damage  to  that  on  the  side  of  the  torn  ureter — very  little 
urine  indeed  was  passed  during  the  few  days  the  patient 
lived. 

A  common  immediate  symptom  is  pain  or  tenderness  at 
the  part  injured.  The  pain  may  be  referred  to  the  loin,  to  the 
front  of  the  abdomen,  to  the  umbilicus,  or  to  the  middle  of 
Poupart's  ligament.  This  pain  may  pass  off  in  a  day  or  two, 
and  the  patient  may  remain  quite  free  till  fresh  pain  is  caused 


138  INJURIES    OF  TEE    URETER. 

by  the  development  of  a  tumour.      Transient  collapse  and 
vomiting  may  occur. 

In  some  of  the  cases  (Stanley's,  Poland's,  and  Godlee's) 
there  was  ecchymosis  over  the  loin,  abdomen,  and  inguinal 
region,  and  in  Stanley's  there  was  extensive  suppuration  of 
the  cellular  tissue  about  the  loin  and  sacrum.  If  the  patient 
survives  the  injury,  a  swelling  will  form  on  the  injured  side  of 
the  abdomen,  or  in  the  corresponding  flank,  within  a  period 
varying  from  a  few  days  to  several  years. 

The  abdominal  swelling  may  be  caused  either  by  a  collec- 
tion of  urine,  or  urine  and  blood,  behind  the  peritoneum,  or  by 
one  or  two  of  the  changes  which  supervene  in  the  kidney 
itself.  If  due  to  a  retroperitoneal  collection,  the  swelling- 
forms  much  earlier  than  when  due  to  change  in  the  kidney 
itself ;  appearing  usually  within  a  few  days  or  weeks  in  the 
first  event,  but  only  within  "  many  weeks,"  months,  or  even 
years  in  the  latter. 

Of  the  five  instances  in  which  the  swelling  was  behind  the 
peritoneum,  it  appeared  within  a  day  or  two  in  Poland's  case, 
at  the  end  of  the  sixth  week  in  Stanley's,  and  within  two  or 
three  weeks  in  the  others. 

The  swelling  is  usually  well  defined,  palpable  from  the  loin 
and  front  of  the  abdomen,  and  is  round,  oblong,  or  sausage- 
shaped.  It  may  extend  from  the  thorax  into  the  false  pelvis, 
and  may  reach  the  median  line  of  the  abdomen. 

The  length  of  time  which  elapses  before  the  a}3pearance  of 
this  tumour,  depends  upon  (1)  the  character  of  the  rupture ; 
(2)  the  degree  of  resistance  to  the  escape  of  the  urine  offered 
by  the  tissue  into  which  it  passes ;  and  (3)  to  the  interference 
— caused  by  the  shock,  or  by  damage — with  the  secreting 
capacity  of  the  kidney. 

The  rent  in  the  ureter  may  be  very  small,  or,  on  the  -other_ 
hand,  the  tube  may  be  torn  right  across.  If  separation  is 
complete,  the  ends  may  possibly  be  curled  up,  as  Tuffier  tells 
us  was  the  case  in  some  of  his  experiments  on  dogs.  Such  a 
condition  would  offer  an  obstacle  to  the  escape  of  urine  ;  it 
was  not,  however,  found  to  have  occurred  in  Poland's  case, 
in  which  the  tear  was  complete,  and  the  ends  separated. 

A  much  more  likely  obstacle  will  be  blood  clotted  over  the 
orifice,  or  around  the  torn  end  of  the  tube.      Blood  clot  may 


INJURIES   OF   THE    URETER.  139 

fill  the  calyces  and  pelvis  of  the  kidney ;  or  the  parenchyma 
of  the  kidney  may  be  compressed  by  blood  extravasated 
beneath  the  capsule  ;  or  the  renal  vessels  may  be  thrombosed. 
Under  any  of  these  circumstances,  urine  would  fail  to  escape 
or  even  to  be  secreted. 

Again,  the  cellular  tissue  may  be  very  dense  and  not  easily 
opened  up,  or  its  meshes  may  be  packed  with  extravasated 
blood,  and  thus  much  opposition  offered  to  infiltration  of 
urine.  The  shock  of  the  accident,  and  the  reflex  suppression 
of  urine  following  the  injury,  would  explain  only  a  certain 
amount  of  delay. 

In  injury  to  the  ureter,  as  in  injury  to  the  renal  pelvis,  it 
is  possible  that  the  escape  of  urine  may  only  follow  the  slough- 
ing out  of  severely  bruised  tissue,  and  not  take  place  as  an 
immediate  consequence  of  the  original  violence. 

When  the  lesion  occurs  on  the  peritoneal  aspeet  of  the 
ureter,  it  is  to  be  expected  that  the  escape  of  urine  will  be 
early  and  profuse,  as  there  is  then  less  resistance  to  the 
outflow  of  urine  ;  and  no  tumour  will  be  likely  to  form  in  the 
flank. 

As  soon  as  the  urine,  or  urine  and  blood,  which  have  col- 
lected in  the  retroperitoneal  space  decompose,  inflammation, 
suppuration,  or  sloughing  occurs,  and  other  symptoms  then 
arise,  namely,  increased  pain,  redness  of  the  skin  in  the  loin, 
oedema  of  the  abdominal  wall,  elevation  of  temperature  to 
101°  or  102°,  or  even  a  degree  or  two  higher,  rigors,  furred 
tongue,  loss  of  appetite,  and  constipation  or  diarrhoea. 

In  both  cases  (Chaput's  and  Pye-Smith's)  in  which  a  com- 
munication between  the  bowel  and  the  urine  cyst  was  found 
to  have  existed,  diarrhoea  or  simulated  diarrhoea  was  a  notice- 
able symptom. 

The  fluid  drawn  off  from  the  tumour,  before  suppuration 
has  commenced,  has  the  characters,  more  or  less  pronounced, 
of  urine,  in  colour,  odour,  and  composition  ;  but  it  is  generally 
slightly  alkaline  in  reaction,  of  a  low  specific  gravity,  e.g.  1008 
to  1010,  and  contains  very  little,  perhaps  only  a  mere  trace  of 
urea.  It  will  probably  also  contain  a  small  quantity  of 
albumin,  a  little  blood,  and  most  likely  a  considerable  amount 
of  chloride  of  sodium.  When  the  parts  become  septic,  the 
fluid  withdrawn  will  also  contain  more  or  less  pus. 


140  INJURIES   OF   THE   URETER. 

In  Chaput's  case  the  fluid  withdrawn  on  the  twelfth  and 
fourteenth  days  after  the  injury  was  sanguinolent,  and  showed 
fatty  globules  and  altered  leucocytes  and  red  blood  corpuscles, 
and  was  thought  to  be  the  fluid  of  a  haematoma  on  its  way  to 
suppuration. 

In  the  five  cases  in  which  the  swelling  was  in  the  kidney 
itself  the  tumour  was  noticed  at  very  different  lengths  of  time 
after  the  injury.  In  one  case  it  is  stated  to  have  been 
'■  several  weeks,"  in  others  it  was  two  years,  four  years,  and 
nine  years  respectively.  In  Fenger's  case,  ten  years  elapsed 
between  injury  and  hydronephrosis,  and  thirty-four  years 
between  the  injury  and  the  ureterotomy  by  which  the  inter- 
mittent hydronephrosis  was  remedied. 

The  nature  of  the  renal  tumour  was  very  different  in  these 
five  cases.  One  was  an  abscess-like  dilatation  of  each  of  the 
calyces  (Haviland's) ;  one  a  pyonephrosis,  the  contained  fluid 
being  opaque  and  reddish  and  loaded  with  pus  and  blood  cells 
(Pye-Smith's) ;  in  another  (Soller's)  it  was  a  large  polycystic 
kidney ;  in  Cabot's  and  Fenger's  cases  the  condition  was 
described  as  hydronephrosis. 

Occurring  at  such  a  long  interval  after  the  accident,  and 
with  the  intervening  period  between  the  injury  and  the 
formation  of  the  renal  tumour,  perhaps,  absolutely  without 
symptoms  of  any  kind,  these  cases  come  to  have  importance 
clinically,  less  in  relation  to  injuries  of  the  ureter  than  to 
renal  enlargements  generally. 

Diagnosis. — If  there  is  at  first  little  or  no  hematuria  and 
no  swelling  in  the  loin,  and  then  after  three  or  four  weeks, 
more  or  less,  a  swelling  forms  behind  the  peritoneum,  rupture 
of  the  ureter  may  be  suspected.  If  many  months  or  even 
years  after  an  injury  in  the  region  of  the  ureter,  a  tumourLofL 
the  kidney  is  formed,  though  there  has  been  an  absence  of 
sj^mptoms,  or  only  slight  hsematuria  at  the  time  of  the  injury, 
there  will  be  ground  for  suspecting  traumatic  contraction  or 
occlusion  of  the  ureter. 

It  is,  however,  impossible  to  distinguish  injured  ureter 
with  extravasation,  from  injured  renal  pelvis  with  extravasa- 
tion ;  injured  ureter  with  complete  obstruction  by  clot  or 
recurved  ends  is  equally  indistinguishable  from  injured  kidney 


INJURIES   OF   THE   URETER.  141 

with  clot  plugging  the  renal  pelvis  or  the  ureter.  Nor  is  this 
impossibility  of  exact  diagnosis  of  any  practical  importance, 
because  the  treatment  must  be  the  same. 

Some  assistance  may  perhaps  be  obtained,  where  an  open- 
ing in  the  ureter  is  believed  to  exist,  by  distending  the  bladder 
with  water.  Kammerer  found  that  the  water  escaped  by  the 
defective  ureter  until  the  bladder  was  quite  distended,  and 
then,  doubtless  through  closure  of  the  valvular  entrance  in 
the  bladder,  the  water  ceased  to  flow.  Le  Fort  and  Page 
applied  this  test  in  their  cases  but  without  effect. 

M.  Turner  thinks  that  a  constant  escape  of  urine,  after  a 
wound  of  the  ureter,  is  the  leading  distinction  between  these 
injuries  and  wounds  of  the  kidney.  Wound  of  the  kidney,  he 
says,  will  cicatrise  easily  and  rapidly,  and  give  rise  to  no 
extravasation  of  urine,  whilst  wounds  of  the  ureter  have  less 
tendency  to  natural  cure.  If  by  "  wounds  of  the  kidney " 
Turner  means  also  wounds  of  the  renal  pelvis,  and  wounds 
opening  the  calyces  through  the  renal  parenchyma,  facts  are 
against  him.  Even  it'  this  were  a  leading  distinction  it  would 
give  no  aid  to  diagnosis  in  subcutaneous  injuries. 

Prognosis. — In  cases  not  complicated  with  other  serious 
injuries,  the  immediate  effect  of  these  accidents  is  not  to 
endanger  life,  if  the  peritoneum  is  uninjured.  If  prompt  and 
decided  surgical  treatment  were  adopted,  the  consequences  to 
the  kidney  itself  would  be  less  unfavourable  ;  and  subsequent 
nephrectomy  would  probably  be  less  frequently  required  than 
has  been  the  case  hitherto. 

When  the  peritoneum  is  involved  the  outlook  is  most 
serious ;  in  both  the  fatal  cases  the  peritoneum  was  injured, 
and  in  one  of  chem  the  cause  of  death  was  peritonitis.  In 
the  other  case  the  wound  in  the  peritoneum  was  not  in  the 
neighbourhood  of  the  kidney  or  ureter,  and  no  evidence  of 
peritonitis  was  found  at  the  post-mortem  examination. 

Treatment. — The  ideal  treatment  for  subcutaneous  rup- 
ture, whether  in  a  longitudinal  or  transverse  direction,  is 
immediate  suture  or  anastomosis  of  the  ureter,  according  to 
the  character  of  the  wound.  But  it  is  useless  to  state  that 
this  is  the  treatment  at  once  to  adopt,  when  the  indications  of 


142  INJURIES  OF  THE    URETER. 

the  exact  injury  do  not  occur  until  weeks  after  the  rupture 
has  taken  place  ;  when  there  is  nothing  even  then  to  indicate 
the  site  of  the  rupture,  and  when  the  retroperitoneal  tissues 
have  become  changed  by  the  pressure  and  inflammation 
caused  by  the  extravasated  fluid. 

Puncture  of  the  retroperitoneal  cyst  has  been  adopted  but 
with  uncertain  result.  Stanley's  doubtful  case  was  tapped  six 
lmes,  and  yet  the  tumour  occurred  again,  and  persisted  as 
long  as  the  boy  was  under  observation.  We  must  remember, 
however,  that  a  repetition  of  punctures  has  been  followed  by 
the  complete  and  permanent  disappearance  of  the  swelling,  in 
cases  of  retroperitoneal  extravasation,  due  to  rupture  of  the 
kidney  or  renal  pelvis,  and  also  in  cases  of  traumatic  hydro- 
nephrosis. Whilst  in  some  of  these  cases,  in  which  the  tumour 
ceased  to  refill,  the  ureter  may  have  become  patent,  it  is 
probable  that  in  most  of  them  the  kidney  ceased  to  secrete, 
and  atrophied — a  result  which  cannot  be  regarded  as  satis- 
factory. 

Lumbar  incision. — A  free  incision  in  the  ilio-costal  space 
will  secure  the  complete  evacuation  of  the  extravasated  fluid  ; 
and  drainage  will  obviate  the  reaccumulation  of  urine  sub- 
sequently escaping  through  the  ruptured  tube.  If  the  ureter 
is  not  completely  torn  across,  the  experience  afforded  by  the 
removal  of  calculi  from  its  upper  end  would  lead  one  to  expect 
the  ultimate  cicatrisation  of  the  wound,  and  the  re-establish- 
ment of  the  ureteral  channel. 

Through  the  lumbar  incision  it  will  be  possible  to  explore 
the  renal  pelvis,  and  if  the  state  of  the  kidney  indicates  that 
the  urine  has  escaped  at  some  point  in  the  ureter,  and  not 
from  the  kidney,  the  loin  incision  may  be  prolonged  in  a 
direction  towards  Poupart's  ligament,  passing  about  a  fmger's- 
breadth  in  front  of  the  anterior  superior  spine  of  the  iliu/m7~ 
It  will  no  doubt  be  very  difficult  to  trace  the  ureter  in  tissues 
which  have  been  changed  in  structure,  and  when  its  normal 
position  is  disturbed  in  consequence  of  the  previous  extra- 
vasation. The  search,  however,  may  be  somewhat  facilitated 
by  remembering  that  the  ureter  is  carried  forward  with  the 
detached  peritoneum ;  and  that  it  is  intimately  attached  to 
that  membrane  about  half  an  inch,  or  little  more,  external  to 
where  the  peritoneum  is  tied  down  to  the  side  of  the  spinal 


INJURIES   OF   THE    URETER.  143 

column.  If  a  rent  in  the  ureter  should  happen  to  be  found,  it 
should  be  repaired  by  suture,  or  ureteral  anastomosis. 

In  none  of  the  cases,  however,  which  have  hitherto  been 
operated  upon  has  the  site  of  the  injury  been  ascertained. 
Page  says  that  the  thought  of  closing  the  wound  by  suture 
occurred  to  him  when  he  laid  the  cyst  open,  but  the  portion 
of  the  ureter  visible  was  intact,  and  as  it  coursed  away  from 
the  region  of  the  kidney  he  did  not  think  it  desirable  to 
follow  it. 

It  is  to  be  expected,  however,  that  by  a  more  extensive 
parietal  incision,  a  freer  search  for  the  rupture,  and  with  the 
aid  of  the  ureteral  catheter,  the  actual  wound  may  be  found 
and  directly  treated  in  future  cases. 

The  proposal  to  apply  an  aseptic  ligature  to  the  torn  upper 
end,  with  the  object  of  inducing  atrophy  of  the  kidney,  is  to 
my  mind  very  unsurgical.  If  the  rent  can  be  closed  by 
sutures,  so  as  to  restore  the  continuity  of  the  ureteral  channel, 
this  should  be  done.  If  the  rupture  cannot  be  found,  the 
loin  incision  followed  by  drainage  will  put  the  damaged  parts 
into  the  most  favourable  condition  for  repair.  We  have 
abundant  evidence  that  wounds  of  the  renal  substance  and 
renal  pelvis,  and  also  of  the  ureter  itself,  made  by  the  surgeon 
for  removing  calculi,  will  ultimately  heal  without  the  aid  of 
sutures.  It  should  be  the  surgeon's  object,  therefore,  to  put 
accidental  wounds  of  the  ureter,  which  he  cannot  localise, 
and  therefore  cannot  suture,  under  the  same  conditions 
favourable  for  cicatrisation,  as  he  places  wounds  of  his  own 
making  in  operations  on  the  kidney  and  its  duct. 

If  the  ureter  is  completely  torn  asunder,  and  its  ends  can 
be  approximated,  they  should  be  united  by  one  of  the  recog- 
nised methods  of  ureteral  anastomosis.  If  its  ends  cannot  be 
joined  together,  then  a  permanent  fistula  opening  on  the  loin 
is  the  result  to  be  expected.  Such  a  fistula,  by  possibly 
saving  the  integrity  of  the  kidney,  would  be  the  means  of 
preserving  the  patient's  life,  if  his  other  kidney  happened  to 
be  destroyed,  or  he  had  but  one.  On  the  other  hand,  if  the 
second  kidney  is  sound,  and  the  fistula  badly  tolerated  by  the 
patient,  nephrectomy  is  the  final  resort. 

In  a  case  of  my  own  (published  in  the  Clinical  Journal, 
1st  August,  1894),  in  which   there  was  rupture  of  the  renal 


144  INJURIES   OF   THE    URETER. 

pelvis,  a  permanent  lumbar  fistula  followed,  and  continued 
(with  two  or  three  short  intermissions,  attended  by  fever  and 
local  inflammatory  symptoms)  for  seven  years.  The  quantity 
of  urine  escaping  by  the  fistula  during  this  time  gradually 
diminished,  and  finally  ceased  ;  and  the  fistula  then  remained 
closed  for  three  years.  At  the  end  of  this  period  fresh  sup- 
puration occurred,  and  an  abscess  was  opened  by  an  incision 
made  through  the  old  scar.  A  purulent  fistula  resulted,  and 
was  attended  with  considerable  pain  and  inflammatory 
swelling  in  the  loin.  On  this  account  an  exploration  was 
made  at  the  end  of  a  few  weeks,  through  an  incision  from  the 
loin  to  the  internal  abdominal  ring.  Search  was  made  of  a 
very  thorough  and  extensive  character,  the  peritoneum  being 
widely  detached  and  raised  inwards  (it  was  also  opened  in  the 
process  accidentally),  but  not  a  trace  of  kidney  could  be 
found,  and  the  ureter  diminished  in  calibre,  and,  tapering 
and  completely  closed  at  its  renal  end,  was  excised.  Recovery 
followed.  In  all  probability  the  renal  pelvis  was  lacerated, 
and  the  ureter  completely  torn  away  from  the  infundibulum 
at  the  time  of  the  accident ;  but  the  condition  could  not  be 
ascertained  at  the  time  of  the  original  opening  of  the  peri- 
nephral extravasation,  nor  in  the  less  extensive  ex- 
ploration which  was  made  two  years  after  the  original 
injury. 

Of  course,  after  lumbar  incision,  it  would  be  requisite  to 
use  all  customary  precautions  against  sepsis;  and  if  this  is 
done  successfully,  and  the  lumbar  incision  has  been  made 
soon  after  the  first  development  of  the  swelling,  there  is  little, 
if  any,  reason  why  the  kidney  should  become  the  seat  of 
suppurative  changes.  It  was,  however,  found  that  the  kidney 
suppurated  in  all  three  of  the  cases  in  which  the  retro- 
peritoneal collection  was  drained ;  but  in  one  of  them 
(Godlee's)  there  was  pus  in  the  fluid  withdrawn  when  the 
cyst  was  first  punctured,  and  before  it  was  laid  open  by 
lumbar  incision.  In  another  (Chaput's)  there  were  special 
conditions  favouring  sepsis,  because  there  was  a  communi- 
cation between  the  large  bowel  and  the  retroperitoneal  collec- 
tion of  urine  ;  and  in  the  third  case  the  drainage  was  imperfect, 
being  made  through  the  linea  semilunaris,  instead  of  through 
the  ilio-costal  space  behind. 


INJURIES   OF   THE   URETER.  145 

Nephrectomy.  —  Nephrectomy  will  be  required,  after 
drainage  has  failed,  if  pus  in  the  extravasated  fluid,  con- 
tinued high  temperature,  or  recurring  pyrexial  attacks,  with 
pain,  loss  of  appetite,  and  emaciation,  make  it  clear  that  the 
kidney  or  the  retroperitoneal  tissue  is  the  seat  of  extensive 
suppuration.  Nephrectomy  may  be  required  also  in  the 
absence  of  suppuration,  if  a  permanent  fistula  has  resulted, 
and  is  a  source  of  intolerable  discomfort  to  the  patient  In 
a  case  of  intraperitoneal  rupture,  ligatures  might  be  applied 
to  the  ends  of  the  ureter  above  and  below  the  wound,  or 
nephrectomy  might  be  indicated ;  but  some  form  of  ureteral 
anastomosis  should  be  practised  if  the  patient's  condition 
warrants  it. 

It  has  sometimes  been  stated  that  primary  nephrectomy 
would  be  the  best  treatment  in  all  cases  of  subcutaneous 
injury,  whether  of  the  kidney,  renal  pelvis,  or  ureter,  attended 
with  retroperitoneal  extravasation  of  urine ;  but  I  am  not  of 
this  opinion.  P.  Wagner,*  though  he  says  that  in  injury  of 
the  ureter  the  kidney  concerned  is  almost  certainly  lost  to  the 
organism,  is,  however,  of  opinion  that  it  is  more  correct  to 
defer  nephrectomy,  and  first  await  the  formation  of  a  ureteral 
fistula,  and  then  make  an  attempt  at  repair,  before  operating 
on  a  kidney  which  is  itself  uninjured. 

Nephrectomy  may  be  entirely  avoided  by  the  rapid 
atrophy  of  the  kidney  after  injury  to  and  obliteration  of  the 
ureter.  Undoubtedly  the  danger  of  primary  nephrectomy 
for  severe  injury  is  not  inconsiderable ;  but,  on  the  other 
hand,  the  chances  of  recovery  after  secondary  nephrectomy 
for  septic  nephritis  are  less  than  after  primary  nephrectomy 
for  injury.  The  chance  of  recovery,  with  perfect  function  of 
the  kidney  on  the  injured  side,  ought,  however,  when  the 
kidney  itself  is  not  irreparably  injured,  to  be  given  to  the 
patient.  This  will  be  done  by  a  prompt  incision  through 
the  loin,  as  soon  as  a  retroperitoneal  swelling  is  formed,  fol- 
lowed by  free  drainage  into  antiseptic  dressings.  Should  this 
not  succeed,  secondary  nephrectomy  will  very  probably  save 
the  life  of  the  patient.  It  did  so  in  all  three  cases  referred 
to  above,  and  has  done  so  in  several  similar  cases,  where  the 
substance  of  the  kidney  or  the  renal  pelvis  has  been  torn. 

*  Deutsche  Ztsehr.  f.  Chir.,  Leipzig,  1892,  Bd.  xxxiv.  S.  102. 


146  INJURIES   OF   THE    URETER. 

In  traumatic  hydronephrosis  a  trial  of  ureterotomy  for 
division  of  the  stricture  should  be  made,  as  was  so  success- 
fully carried  out  in  Fenger's  case. 

Abstracts  of  the  Eleven  Cases  regarded  as 
Subcutaneous  Ureteral  Injuries. 

Group  A. — Case  1. — Poland's  case*  was  that  of  a  woman,  set. 
thirty-three,  in  the  fifth  month  of  pregnancy,  who  was  squeezed  and 
slowly  twisted  half  a  revolution  between  the  platform  and  the  foot- 
board of  a  railway  carriage.  On  admission  there  was  a  small  superficial 
wound  of  the  abdominal  wall,  about  l-§  inch  to  the  left,  and  a  little 
above  the  umbilicus,  with  a  subcutaneous  laceration  of  the  peritoneum 
and  rectus  muscle  sheath,  through  which,  on  the  fourth  day,  16  inches 
of  intestine  bulged.  On  the  fifth  day  she  aborted,  and  on  the  sixth 
died  of  asthenia. 

A  few  drops  of  urine  were  passed  on  the  afternoon  of  the  fourth 
day,  but  as  this  was  with  the  motion,  and  was  thrown  away  by  the 
nurse,  it  was  not  ascertained  whether  blood  was  mixed  with  it  or  not. 

A  post-mortem  examination  revealed  fracture  of  the  spinous  pro- 
cesses of  all  the  lumbar  vertebra?,  both  twelfth  ribs,  and  both  transverse 
processes  of  the  upper  three  lumbar  vertebrae.  The  right  lumbar  region 
was  raised  into  a  great  dark  swelling  by  blood  effusion.  The  right 
ureter  was  torn  quite  across,  just  below  the  pelvis  of  the  kidney,  so  that 
it  terminated  in  a  ragged  end  in  the  midst  of  the  half-sloughy,  putre- 
scent, jelly-like  tissues  which  surrounded  the  organ.  The  capsule  of  the 
right  kidney  was  separated  from  the  parenchyma  by  a  considerable 
quantity  of  blood  clot,  extravasated  over  the  anterior  aspect  of  the 
organ,  and  prevented  the  mixing  of  this  blood  with  the  urine  extra- 
vasated from  the  ruptured  ureter.  The  blood  under  the  capsule  was 
derived  from  a  rent  on  the  posterior  and  lower  part  of  the  organ,  which 
penetrated  to  and  opened  a  vein  at  the  base  of  one  of  the  pyramids. 
The  left  kidney  was  in  a  very  remarkable  condition  ;  it  had  a  buff-pink 
or  yellow-clay  colour,  very  opaque  and  dead-looking.  On  section,  the 
whole  of  the  vessels  were  blocked  up  with  ante-mortem  clot,  which 
extended  in  both  artery  and  vein  to  the  principal  vessel.  In  the-trunk- 
vein  the  clot  was  non-adherent ;  in  the  artery  it  was  firmly  adherent, 
but  there  was  no  wound  of  the  arterial  coats. 

With  such  extensive  damage  to  the  kidney  tissue  it  is  impossible  to 
draw  any  accurate  conclusions  from  this  case  as  to  the  symptoms  due 
to  rupture  of  the  ureter. 

The  suppression  of  urine  was  evidently  due  to  compression  of  one 
gland  by  subcapsular  haemorrhage,  and  thrombosis  of  all  the  vessels  of 
the  other.  The  case,  besides  other  points  of  interest,  affords  an  illus- 
tration of  subcapsular  extravasation  of  blood  in  the  kidney,  a  form  of 

*  Gmfs  Hosp.  Eq>.,  London,  1868,  3rd  series,  vol.  xiv.  p.  S6. 


INJURIES   OF  THE    URETER.  147 

injury  to  which  attention  has  not  yet  been  specially  drawn,  but  of  which 
I  have  seen  three  or  four  marked  instances. 

Case  2. — Coull  Mackenzie's  case  is  the  only  example  of  extravasation 
of  urine  into  the  peritoneal  cavity,  due  to  a  subcutaneous  injury  of  the 
ureter.* 

It  is  that  of  a  coolie  who  was  jammed  between  two  heavy  trucks. 
There  was  no  external  mark  of  injury.  There  were  two  small  ruptures, 
each  the  size  of  a  pea,  in  the  right  ureter.  The  abdominal  cavity  con- 
tained two  pints  of  urine  mixed  with  blood.  The  patient  died  from 
peritonitis,  following  the  extravasation  through  the  ruptures  of  the 
ureter.  This  case  affords  no  special  symptoms  beyond  such  as  are 
-caused  by  fatal  perforative  peritonitis. 

Group  B. — Four  cases  (Stanley's,  Godlee's,  Chaput's,  and  Page's), 
in  each  of  which  there  was  a  retroperitoneal  collection  of  urine,  were 
possibly  instances  of  rupture  of  the  ureter. 

Case  3.— Stanley,  t  in  a  paper  on  rupture  of  the  ureter,  records  the 
•case  of  a  boy,  aet.  nine,  who  was  squeezed  between  the  wheel  of  a  cart 
and  the  curb-stone.  The  immediate  consequences  were  contusion  of 
the  soft  parts  around  the  pelvis,  and  great  pain  in  the  lower  part  of  the 
abdomen,  much  ecchymosis  and  extensive  suppuration  in  the  sub- 
cutaneous cellular  tissue  around  the  pelvis,  from  which  several  ounces 
of  matter  were  discharged  by  puncture  near  the  left  sacro-iliac  syn- 
chondrosis. By  the  end  of  the  sixth  week  these  soft  parts  had  recovered, 
but  a  large,  circumscribed,  oblong  swelling  was  found  in  the  right  side 
of  the  abdomen.     The  urine  was  passed  naturally  throughout. 

From  this  swelling,  fluid  having  some  of  the  characters  of  urine  was 
withdrawn  by  puncture  with  a  small  trocar  and  cannula.  The  swelling 
recurred  again  and  again. 

It  was  punctured  altogether  six  times  in  a  period  of  five  months  and 
a  half.  It  refilled  again,  and  extended  from  the  linea  alba  to  the  right 
lumbar  region,  but  further  evacuation  was  considered  inexpedient,  and 
the  boy  was  discharged  from  the  hospital  nine  months  after  the 
accident.  Subsequently  he  was  often  seen  in  good  health,  but  with  the 
abdominal  swelling  distinct. 

Thus  in  this  case  of  Stanley's,  which,  ever  since  Poland  referred  to 
it  in  1868,  has  been  quoted  over  and  over  again  as  one  of  ruptured 
ureter,  we  have  no  proof  whatever  of  the  exact  part  injured,  nor  of  the 
ultimate  result  of  the  injury.  It  is  more  likely  to  have  been  a  ruptured 
renal  pelvis  than  a  ruptured  ureter. 

Stanley  states  that  by  his  exploratory  puncture  he  learnt  that  the 
fluid  was  situated  immediately  beneath  the  abdominal  muscles,  and  had 
formed  for  itself  a  cavity,  by  detaching  the   peritoneum  from  the 

*  "Med.-legal  Experiences  in  Calcutta,"  Edinburgh,  p.  98. 
t  Med.-Chir.  Trans.,  London,  1844,  vol.  xxvii. 


148  INJURIES   OF   THE    URETER. 

abdominal  and  lumbar  muscles.  As  to  the  source  of  the  effused  urine, 
he  quotes  the  opinion  of  Mr.  Taylor,  who  analysed  the  fluid,  "that, 
owing  to  the  absence  of  mucus  in  it,  the  probable  source  was  high  up  in 
the  urinary  apparatus,  as  at  the  commencement  of  the  ureter."  This 
means  only  that  Mr.  Taylor  did  not  think  the  urine  he  examined  had 
remained  in  the  bladder. 

The  other  case  in  Stanley's  paper  is  specifically  stated  by  Stanley  as 
being  one  of  ruptured  pelvis  of  the  right  kidney,  the  nature  of  the 
injury  having  been  ascertained  by  post-mortem  examination. 

Case  4 — R.  J.  Godlee,*  in  an  interesting  communication  in  May, 
1887,  on  "Three  Cases  of  Abdominal  Cysts  following  Injury,"  recorded 
the  case  of  a  little  girl,  set.  4,  who  had  been  run  over  by  a  cab.  Pain, 
tenderness,  and  burning"  in  the  left  inguinal  and  lumbar  regions 
resulted.  Nothing  further  was  revealed  until  a  fortnight  had  elapsed, 
when  an  indefinite  swelling  in  these  parts  was  detected.  Within  three 
weeks  from  the  date  of  injury,  this  had  developed  into  a  large,  well- 
defined,  fluctuating  tumour,  which  extended  from  the  iliac  spine  to  the 
level  of  the  eighth  rib,  and  reached  to  within  half  an  inch  of  the  median 
line  in  front.  No  change  had  been  observed  in  the  urine.  By  the 
aspirator  a  large  quantity  of  turbid  alkaline  urine  was  withdrawn,, 
containing  3  per  cent,  of  urea,  much  albumin  and  mucus,  a  small 
quantity  of  pus,  and  some  phosphate  crystals.  The  cyst  refilled  within 
two  days,  to  the  same  size  as  before.  At  the  end  of  one  month  from 
the  date  of  the  injury,  an  incision  was  made  in  the  ilio-costal  space,  and 
a  drain  inserted.  Then  followed  a  copious  and  persistent  leakage  of 
urine  from  the  wound  and  a  series  of  pyrexial  attacks,  so  that,  at  the 
end  of  three  months  and  a  week  after  the  original  injury,  lumbar 
nephrectomy  was  performed. 

Mr.  Godlee  had  great  difficulty  in  finding  the  kidney,  which  was 
situated  at  the  upper  and  anterior  part  of  the  sac,  pushed  forward  with 
the  peritoneum ;  and  great  difficulty  in  removing  it,  as  it  was  em- 
bedded in  dense  fibrous  tissue.  The  child  recovered,  but  with  a 
fistula. 

It  was  assumed  before  the  nephrectomy  was  undertaken  that  the 
ureter  was  completely  ruptured,  "  because  no  blood  had  appeared  at  any 
time  in  the  urine,  and  if  the  laceration  had  been  in  the  kidney  it  would 
probably  by  this  time  have  closed."  The  history  of  cases  of  injury- 
to  the  kidney  shows,  however,  that  these  reasons  are  not  sufficient  for 
this  conclusion. 

The  absence  of  blood  in  the  urine,  and  the  persistence  of  the  escape 
of  urine  from  the  wound  prior  to  the  nephrectomy,  are  symptoms  which 
have  often  been  met  with  in  cases  of  ruptured  renal  pelvis. 

No  description  is  given  of  the  kidney  removed,  and  one  is  led  to 
infer  that  it  was  taken  away  piecemeal,  and  that  it  was  impossible  to 
tell  whether  the  renal  pelvis  and  the  renal  substance  had  been  injured 

*  Trans.  Clin.  Soc,  London,  vol.  xx.  p.  219. 


INJURIES   OF  THE    UBETEB.  149 

in  the  first  place  or  not.  There  is  difficulty  in  accepting  the  fistula  in 
this  case  as  evidence  that  the  ureter  was  torn  across ;  it  seems  im- 
probable that  a  detached  portion  of  the  tube  would  cause  more  trouble 
than  the  open  end  of  the  ureter,  or  even  a  large  part  of  the  expanded 
renal  pelvis,  which  in  many  cases  has  been  left  behind  to  form  part  of 
the  stump  of  the  pedicle. 

Case  5. — M.  Chaput*  reported  the  case  of  a  lad,  set.  16,  who  is 
described  as  having  had  his  right  ureter  and  the  back  of  the  caecum 
ruptured  by  a  kick  from  a  horse's  hock  in  the  right  flank.  The  case  was 
one  of  great  difficulty  of  diagnosis,  and  the  operative  treatment  was 
complicated  by  opening  the  peritoneum  and  the  front  wall  of  the 
caecum.  The  surgical  wound  in  the  front  and  the  traumatic  rupture 
of  from  1  to  2  cms.  in  the  back  of  the  caecum  were  sutured,  and  a  large 
perinephric  extravasation  was  incised  and  drained  through  the  loin,  but 
subsequently  the  kidney  was  removed,  because  of  the  persistence  of  the 
fistula  and  the  general  state  of  the  patient.  An  examination  of  the 
kidney  after  removal  showed  it  to  be  in  a  state  of  general  ascending 
suppurative  pyelonephritis.  Its  lower  extremity  was  very  friable,  and 
bathed  in  a  collection  of  pus.  The  renal  pelvis  was  quite  intact,  and 
absolutely  without  sign  of  rupture,  as  was  also  the  ureter  for  a  distance 
of  from  1  to  2  cms.,  but  the  actual  seat  and  nature  of  the  rupture  below 
this  point  was  not  ascertained. 

It  is  a  question  whether  the  friable,  pus-bathed  condition  of  the 
lower  end  of  the  kidney  was  due  to  injury  which  had  ruptured  the 
calyces  and  allowed  escape  of  urine  into  the  surrounding  tissues,  or 
whether  it  was  due  to  changes  subsequent  to  rupture  of  the  ureter. 

Case  6. — Herbert  W.  Page,  Ann.  Sui^g.,  St.  Louis  (May,  1894) 
reported  the  case  of  a  boy,  set.  5,  who  was  knocked  down  on  September 
24th,  1892,  by  a  light  vehicle,  the  wheel  of  which  was  said  to  have 
passed  over  the  abdomen. 

There  was  no  immediate  evidence  of  injury,  but  within  two  days 
blood  was  noticed  occasionally  in  the  urine. 

The  temperature  rose  to  100°  and  102°  on  two  days,  and  then  re- 
turned to  normal.  Twenty  days  after  the  injury  the  temperature  rose 
again  to  100°  and  103°,  and  a  swelling  formed  in  the  right  iliac 
fossa,  accompanied  by  abdominal  tenderness  and  impaired  respiratory 
movements. 

On  27th  October  the  abdomen  was  opened  along  the  right  linea 
semilunaris,  and  some  clear  serous  fluid  escaped  from  the  peritoneal 
cavity. 

Forty  ounces  of  fluid,  having  some  of  the  characters  of  urine,  were 
removed  from  the  swelling  behind  the  peritoneum,  the  edges  of  the 
cyst  wall  were  attached  to  the  anterior  parietal  peritoneum,  and  the 
space  drained. 

*  Bull,  et  mem.  Soc.  de  ehir.  de  Paris,  13  Mars,  1889. 


150  INJURIES   OF   THE   URETER.] 

The  kidney  and  upper  two  inches  of  the  ureter  were  exposed  to  view,, 
and  found  to  be  uninjured  and  healthy.  The  ureter  below  this  part  was 
not  visible,  and  it  was  concluded  that  the  urine  had  escaped  through  a 
rupture  in  it  lower  down. 

In  November  nephrectomy  was  performed,  because  of  the  continued 
scape  of  purulent  urine  from  the  retroperitoneal  cavity  and  the  high 
ever.  The  kidney  was  then  found  to  be  three  times  its  normal  size, 
and  in  a  state  of  ascending  suppurative  nephritis,  the  renal  pelvis  was 
distended  with  purulent  urine,  and  this,  as  well  as  the  upper  part  of  the 
ureter,  was  entire.  The  bladder  had  previously  been  proved  by  injection 
to  be  intact.  The  child  ultimately  recovered  completely.  The  actual 
lesion  of  the  ureter,  however,  was  never  seen,  and  some  doubt  may 
possibly  be  felt  about  it. 

Group  C. — The  five  cases  on  record  in  which  either  abscess-like 
dilatation  of  the  calyces  of  the  kidney,  polycystic  disease,  or  hydrone- 
phrosis has  been  attributed  to  injury  of  the  ureter,  are  the  following  : — 

In  three  of  them  (Haviland's,  Pye-Smith's,  and  Soller's)  it  was  proved 
post-mortem  that  the  ureter  of  the  affected  kidney  was  at  some  point 
contracted  or  obliterated,  and  the  history  in  each  case  suggests  that  this 
might  have  been  caused  by  an  injury  to  the  loin,  received  at  periods  of 
four,  two,  and  nine  years  respectively  before  death. 

In  the  fourth  case  (Cabot's),  recovery  without  a  fistula  ensued  after 
nephrotomy  and  drainage.  The  exact  nature  of  the  injury  in  this  case 
was  not  ascertained,  and  it  is  therefore  not  possible  to  say  that  it  was 
the  ureter  and  not  the  renal  pelvis  that  was  damaged. 

The  fifth  case,  Fenger's,  was  one  of  subcutaneous  injury,  followed  by 
stricture  of  the  ureter,  and  resulting  in  intermittent  hydronephrosis.  It 
was  cured  by  ureterotomy,  with  closure  of  the  divided  wall  of  the 
strictured  portion  by  the  Heinecke-Mikulicz  method. 

Case  7. — In  Haviland's  case,*  a  lad,  set.  18,  sustained  a  fall  on  his 
back  from  a  height  of  20  ft.,  four  years  before  his  death.  For  several 
years  he  had  been  subject  to  a  painful  incontinence  of  urine,  great 
pains  in  the  loins  and  urinary  passages,  the  urine  being  throughout 
charged  with  pus  and  sometimes  with  blood.  After  death  the  right 
kidney  was  found  to  have  lost  all  its  original  structure,  and  to  be 
converted  into  a  series  of  sacs,  containing  pus-like  fluid,  each  "cavity- 
being  lined  with  a  distinct  membrane,  which,  when  separated,  preserved 
its  shape.  The  cavities  appeared  to  have  no  outlet,  and  the  ureter  was 
atrophied  and  impervious. 

Some  doubt  must  be  felt  as  to  this  condition  being  the  result  of 
injury  rather  than  of  tuberculous  disease,  especially  when  we  consider 
the  history  and  the  changes  in  other  parts  of  the  urinary  organs.  Thus 
the  right  kidney  contained  a  similar  cavity,  and  the  corresponding  ureter 
was  considerably  enlarged  and  embedded  in  fat,  in  which  were  a  great 

*  Trans.  Path.  Soc,  London,  1895,  vol.  x.  p.  209. 


INJURIES   OF   THE    URETER.  151 

number  of  indurated  lymphatic  glands  ;  the  bladder  was  contracted  and 
its  mucous  membrane  covered  with  pus,  the  urethra  being  in  a  similar 
condition. 

The  parents  attributed  the  boy's  illness  to  his  fondness  for  bathing, 
affirming  that  up  to  his  thirteenth  year  he  was  perfectly  healthy. 

The  fall  seems  to  have  occurred  about  a  year  later  than  this,  when 
the  lad  was  fourteen,  and  he  only  received  a  shaking,  from  which  he  soon 
recovered. 

Case  8. — In  Pye-Smith's  case,*  a  young  farrier,  uet.  24,  had  been 
frequently  kicked  in  the  abdomen,  and  on  one  occasion,  about  two 
years  before  death,  hematuria  of  several  days'  duration  occurred  after 
a  kick  from  a  horse  on  the  left  side,  "  under  the  short  ribs."  He  was 
only  in  bed  three  days,  and  after  recovering,  till  his  last  illness,  felt  no 
inconvenience  and  had  no  return  of  blood  in  the  urine. 

The  final  illness  was  ushered  in  with  diarrhoea  and  an  abdominal 
tumour,  attended  with  pain  and  vomiting.  The  tumour  was  tapped 
more  than  once,  and  several  pints  of  opaque  reddish  fluid  containing  pus 
and  blood  cells  were  drawn  off.  Diarrhoea  recurred,  and  ended  in  the 
patient's  death.  On  post-mortem  examination  the  kidney  was  found 
dilated  into  a  series  of  sacculi,  communicating  with  each  other  and  with 
the  renal  pelvis,  and  contained  a  yellow  puriform  fluid,  like  that  which 
had  been  removed  during  life.  A  communication  had  been  established 
between  the  interior  of  the  kidney  and  the  adherent  descending  colon, 
which  explained  the  diarrhoea  and  the  presence  of  intestinal  matter  in 
one  of  the  renal  pouches.  The  ureter  was  dilated  for  1|  inch,  when  it 
suddenly  became  contracted,  so  as  not  to  admit  the  smallest  probe. 
A  few  lines  further  on  it  again  assumed  its  normal  size.  Dr.  Pye-Smith 
seems  to  have  taken  pains  to  exclude  calculus,  tubercle,  and  other 
possible  causes  of  the  ureteral  contraction. 

Case  9. — M.  J.  Soller,  Interne  des  Hopitaux  de  Lyon,t  reported  the 
case  of  a  joiner,  sat.  45,  who  nine  years  before,  during  the  campaign  of 
1870,  received  in  the  left  hypochondrium,  below  the  last  rib,  a  blow 
from  the  bursting  of  a  shell,  which  did  not  penetrate  or  even  involve  the 
skin.  After  the  injury  he  felt  continually  a  violent  pain  on  the  left 
side,  at  the  level  of  the  part  struck,  which  was  augmented  by  cold  or 
changes  of  temperature.  A  year  and  a  half  afterwards  his  left  testicle 
suppurated,  but  recovered.  The  pain  in  the  left  hypochondrium  led  to 
difficulty  in  respiration,  amounting  almost  to  suffocation,  and  was  accom- 
panied by  violent  beating  of  the  heart.  These  symptoms  increased  up 
to  1879,  when  the  signs  of  nephritis  developed,  and  were  followed  by 
ascites,  anasarca,  anaemia,  convulsions,  and  death  in  August,  1880. 

At  the  post-mortem  the  left  kidney  was  enlarged  one-third,  and 
consisted  of  a  congeries  of  cysts  of  varying  sizes  and  contents,  separated 

*  Trans.  Path.  Soc,  London,  1872,  vol.  xxiii.  p.  159. 
f  Lyon  mkl.,  1880,  tome  xxxv.  p.  333. 


152  INJURIES   OF  THE   URETER. 

by  partitions  of  fibrous  tissue.  All  the  renal  tissue  had  disappeared. 
There  was  considerable  hydronephrosis,  and  the  renal  pelvis  was  filled 
with  seropurulent  fluid.  The  ureter  was  the  size  of  a  quill  pen,  with 
thickened  walls,  and  in  the  middle  of  its  course  it  was  so  contracted  as 
to  scarcely  admit  the  head  of  a  pin.  At  the  level  of  the  contraction  of 
the  ureter  the  cellular  tissue  surrounding  was  indurated  and  chronically 
inflamed.     The  right  kidney  was  very  much  congested. 

This  was  not  a  case  of  rupture,  but  of  contusion  of  ureter,  I  should 
say.  Had  there  been  rupture  there  would  surely  have  been  extravasa- 
tion. If  the  conglomerate  cystic  condition  was  (and  in  all  probability 
it  was)  developed  after  the  accident,  it  supports  the  theory  of  the  cysts 
being  due  to  obstruction,  not  to  an  adenomatous  change. 

Case  10. — Dr.  A.  T.  Cabot*  reported  the  case  of  a  boy,  set.  10  years, 
who  for  three  or  four  days  after  falling  down  stairs  passed  bloody  urine, 
and  several  weeks  later  developed  a  swelling  which  increased  into  a 
prominent  fluctuating  tumour,  filling  the  right  side  of  the  abdomen. 

It  was  twice  aspirated,  and  large  quantities  of  a  clear,  slightly  yellow 
fluid,  having  the  characters  of  altered  urine,  were  withdrawn.  The  fluid 
was  alkaline,  had  a  specific  gravity  of  1007,  and  contained  one-fourth  of 
albumin,  red  and  white  blood  corpuscles,  and  large  round  cells  in 
varying  numbers.  Urea  in  small  amount  was  discovered  at  the  second 
tapping.  As  the  fluid  re-accumulated,  a  vertical  incision  was  made  in 
the  ilio-costal  space,  and  the  cyst  wall  incised  and  stitched  to  the  skin. 
"  The  finger  passed  into  the  cavity  felt  a  soft  nodular  mass,  probably  the 
kidney,  in  the  posterior  part  of  the  cyst.  The  ureter  could  not  be  felt." 
Between  two  and  three  kinds  of  amber-coloured  fluid  escaped,  having 
similar  characters  to  that  previously  withdrawn,  but  in  addition  indican, 
chlorine,  uric  acid,  and  triple  phosphate  crystals,  and  round  cells  like 
renal  epithelium,  were  noted. 

The  boy  recovered  without  fistula,  five  and  a  half  weeks  after  the 
operation.  The  case  was  reported  by  Cabot  as  one  of  "nephrotomy 
fur  hydronephrosis,"  and  the  treatment  described  of  the  cyst  wall,  the 
character  of  the  fluid,  and  the  position  on  the  posterior  instead  of  on  the 
anterior  wall  of  the  cyst,  of  what  he  took  to  be  the  kidney,  support  this 
view.  There  is  nothing  in  the  description  which  is  proof  of  the  injury 
having  been  ruptured  ureter.  The  case  was  doubtless  one  of  traumatic 
hydronephrosis,  from  blood  plugging  the  ureter. 

Case  11. — Fenger's  case  was  published  in  the  Chicago  Medical 
Recorder  for  March,  1893.  It  is  described  by  Fenger  himself  as 
one  of  "  traumatic  stricture  of  the  ureter  close  to  its  entrance  into  the 
pelvis  of  the  kidney,"  causing  intermittent  hydronephrosis.  The  patient, 
who  was  47  years  of  age,  had  sustained  an  injury  thirty-four  years 
previously.  Hydronephrosis  developed  ten  years  afterwards.  Lumbar 
nephrotomy   disclosed   no   calculi.     The   ureteral   orifice  could  not  be 

*  Boston  Med.   and  S.  Journ.,  22nd  February,  1883. 


INJURIES   OF  THE   URETER. 


153 


discovered  through  the  renal  incision  ;   the  dilated  pelvis  was  then 

explored,  but  still/the  orifice  of  the  ureter  could  not 

be  found.      The  ureter  was  then  isolated,  and  its 

upper    end   found    to    be   embedded    in   cicatricial 

tissue  for  half  an  inch.     Lower  clown,  though  small 

in  calibre,  the  duct  was  normal. 

A  longitudinal  incision,  1  cm.  long,  was  made 
in  the  ureter  just  below  the  cicatrix.  The  stricture 
itself  was  1  cm.  in  length,  and  was  incised  upwards 
into  the  renal  pelvis.  The  ureteral  wound  was  then 
stitched  longitudinally,  according  to  the  Heinecke- 
Mikulicz  procedure  in  the  treatment  of  pyloric 
stricture.  No  bougie  was  left  in  the  ureter.  A 
drainage  tube  was  passed  into  the  pelvis  through  the 
wound  in  the  kidney.  The  patient  made  a  good 
recovery  without  return  of  the  hydronephrosis.  This 
operation  was  performed  on  26th  November,  1892. 


Case  12.— Morris's  case  was  incomplete  when 
published  in  the  Clinical  Journal  of  1st  August, 
1894. 

A  strongly-built  man,  set.  30,  fell  from  his  van, 
one  of  the  wheels  of  which  caught  him  a  blow  in 
the  right  loin.  This  was  on  30th  September,  1887. 
One  of  his  ribs  was  fractured,  and  he  passed  a 
little  blood  from  his  bowel  for  a  few  days  ;  but  no 
blood  was  detected  in  his  urine  at  any  time. 
Morphia  was  required  to  relieve  abdominal  pain 
during  some  days.  On  26th  October,  though  he  had 
been  resting  the  whole  time  since  the  accident,  a 
painful  swelling  appeared  in  his  right  loin,  which 
rapidly  increased.  The  next  day,  27th  October, 
Mr.  Morris  made  a  lumbar  incision  and  let  out  over 
100  oz.  of  slightly  blood-stained  urine.  A  large 
rent  was  felt  in  the  renal  pelvis,  but  it  was  not 
detected  at  the  time  that  the  ureter  was  torn  away 
from  the  infundibulum.  A  permanent  drain  was 
kept  up,  and  from  24  to  30  oz.  of  urine  daily 
passed  through  the  right  loin  ;  a  similar  quantity 
was  passed  by  the  bladder. 

In  September,  1888,  he  returned  with  a  large 
swelling  in  the  right  loin,  which  had  formed  since 
he  had  discontinued  the  drainage,  and  the  fistula  had 
been  allowed  to  close.  This  swelling  was  eva- 
cuated, more  pus  than  urine  escaping,  and  the  drain 
re-introduced.  The  same  neglect  of  drainage  was 
followed  by  the  same  sequence  of  events  in  June,  1889. 


NATURAL 
SIZE 


Fig.  29.— Ureter  re- 
moved  ten  years 
after  rupture. 


An  ineffectual 


154  INJURIES   OF   THE    URETER. 

search  was  made  at  this  time  for  the  kidney,  with  a  view  to 
nephrectomy.  A  drainage  tube  attached  to  a  urinal  was  again 
introduced,  and  he  was  urged  to  continue  to  wear  it.  This  he  did — 
following  his  occupation,  and  in  perfect  health  the  while — till  the  fistula 
finally  closed  in  July,  1894.  The  amount  of  urine  discharged  through 
the  fistula  had  for  a  long  time  previously  been  gradually  diminishing. 
He  remained  well  till  October,  1897,  when  a  fresh  abscess  formed,  and 
was  opened  through  the  old  scar.  This  did  not  quite  heal  up,  but 
swelled  up  and  became  inflamed  from  time  to  time.  For  this  reason 
he  requested  to  have  another  operation.  On  15th  November,  1897, 
a  long  curvilinear  incision  was  made,  as  for  nephro-ureterectomy,  and 
a  most  careful  and  thorough  search  instituted  for  the  kidney.  Only 
a  flattened  fig-shaped  mass  of  fibrous  tissue  occupied  the  place  of  the 
kidney.  The  ureter  was  next  sought  for  where  it  crosses  the  iliac 
vessels,  and  was  found  and  traced  nearly  up  to  this  fibrous  mass.  As 
this  point  was  reached,  and  whilst  a  little  traction  was  being  made  upon 
the  ureter,  it  tore  away  from  its  upper  connections.  It  was  a  very 
slender  tube,  quite  closed  at  its  renal  end,  where  it  has  the  appearance 
faithfully  shown  in  the  accompanying  figure.  The  man  made  an 
excellent  recovery. 

Group  D. — Cases  usually  quoted  as  rupture  of  the  ureter,  but 
which  are  really  cases  of  rupture  of  the  renal  pelvis,  or  renal  substance 
opening  calyces. 

Allingham,  H. — Brit.  Med.  Joum.,  London,  1891,  vol.  i.  p.  699. 
Bardenheuer. — "Drainerung  der  peritonealhohle,"  1881,  S.  1733. 
Barker. — Lancet,  London,  17th  January,  1885.  Bennett,  May. — 
Brit.  Med.  Joum.,  London,  1883,  vol.  i.  p.  669.  Croft. — Trans. 
Clin.  Soc,  London,  1881,  vol.  xiv.  (traumatic  hydronephrosis). 
Dumenil,  M.,  quoted  by  Le  Dentu,  "Affections  chirurgicales,"  1889. 
Harrison. — "  Surgical  Diseases,"  p.  328  ;  "  Lectures  on  Surgical 
Disorders  of  the  Urinary  Organs,"  1880.  Hicks. — Med.  Rec, 
N.  Y.j  17th  April,  1880  (traumatic  hydronephrosis).  Hilton. — 
Guy's  Ilosp.  Rep.,  London,  1867,  3rd  series,  vol.  xiii.  Joel. — 
Bull.  Soc.  med.  de  la  Suisse  Rom.,  Lausanne,  July,  1870.  Stanley. 
— Med.-C'hir.  Trails.,  London,  1844,  vol.  xxvii. 

Additional  Bibliography  of  Injuries  to  the  Ureter. 

Cabot,  A.  T. — "Anatomy  and  Surgery  of  the  Ureter,"  Am.  Joum. 
Med.  Sc,  Phila.,  1892,  p.  43.  Collins,  W.  J.—"  Traumatic 
Hydronephrosis,"  Brit.  Med.  Joum.,  London,  1892,  vol.  i.  p.  889. 
Fenger,  Christian. — Chicago  Med.  Rec,  March,  1883,  p.  165  ; 
"  Surgery  of  the  Ureter,"  Trans.  Am.  Surg.  Ass.,  vol.  xii.  p.  130  ; 
Discussion,  p.  169,  May,  1894 ;  and  Ann.  Surg.,  St.  Louis,  1894, 
vol.   xx.    Hook,  van. — Joum.  Am.    Med.  Ass.,   December,  1893, 


INJURIES   OF  THE    URETER.  155 

p.  914.  Keen,  W.  W.—Ann.  Surg.,  St.  Louis,  August,  1896. 
Le  Dentu. — "Affections  chirurgicales  des  reins,  des  ureteres," 
Paris,  1889.  Page,  H.  W— "  On  Traumatic  Ruptures  of  the 
Ureter,  with  Report  of  a  Case  of  Ruptured  Ureter  followed  by 
Nephrectomy,"  Ann.  Surg.,  St.  Louis,  May,  1894,  p.  513.  Tuffiek, 
M. — "  Plaies  du  rein,  ruptures  et  plaies  des  ur6teres,"  Arch.  gen.  de 
mkl,  Paris,  1888,  vol.  i.  p.  335;  "  Traumatismes  de  1'uretere,' 
Traite  cle  chirurgie,"  par  Duplay  et  Reclus,  vol.  vii. 


Ibunterian  Xectures  for  1898. 


TABLES  OF  TWO  HUNDRED  AND  SIXTY-SEVEN  CASES 
OF  RENAL  OPERATIONS  PERFORMED  BY  THE 
AUTHOR  UP  TO  THE  FIRST  WEEK  IN  MARCH, 
1898;  TOGETHER  WITH  A  TABLE  OF  FORTY- 
NINE  COLLECTED  CASES  OF  OPERATION  FOR 
CALCULOUS   ANURIA 


TABLE    L— CASES    OF 

PERFORMED  BY 


Yeae. 


No. 


Initials.       Sex, 


Age. 


Leading  Symptoms. 


1880 


M   M. 


Female. 


19 


1884 


1886 


1887 
(P) 


1888 


1889 


1889 


E.  G. 


J.  M. 


Mr.H. 


Male. 


Male. 


Male. 


A.  H. 


Female. 


K.  V. 


Female. 


24 


42 


25 


26 


21 


J.  H.  M. 


Male. 


27 


Excessive  pain  and  tender- 
ness in  right  loin.  Great 
hematuria,  quite  dis- 
abling her  from  work. 
Symptoms  acute  for  17 
months.  Occasional  pain 
in  right  side  for  11  years. 


Shooting  pains  to  left  testis, 
and  tenderness  in  left 
loin.  Some  haematuria. 
Frequency  of  micturition. 
Symptoms  for  2  years. 

Pain  in  right  loin.  Haema- 
turia. Symptoms  for  19 
years. 

Tenderness  and  aching  in  left 
loin.  Haematuria  and 
slight  pyuria.  Never  colic. 
Kidney  felt  hard.  Symp- 
toms 9  years ;  worse  of 
late. 


Pain  in  both  loins,  but  chiefly 
in  right,  for  4  years.  He- 
maturia. Slight  pyuria. 
Oxalate  of  lime  crystals. 
Tenderness  in  right  loin. 
Frequency  of  micturition 
for  1  year. 

Pain  in  right  loin  for  4  years. 
Swelling  for  1  week,  which 
is  freely  movable.  Haema- 
turia and  albuminuria. 


Pain  and  passage  of  calculi. 
Slight  pyuria.  Repeated 
attacks  of  pain  for  8  years. 


NE  PHROLITHOTOM  Y. 

MR.  HE XRY  MORRIS. 


Date  op  Operation. 


Feb.  11  tli,  1880,  R.  Kidney. 


May  10th,  1884,  L.  Kidney. 


May  15th,  1886,  R.  Kidney. 


Mar.  16th,  1887,  L.  Kidney. 


Jan.  18th,  1888,  R.  Kidney. 


May  22nd,  1889,  R.  Kidney. 


July  31st,  1889,  R.  Kidney. 


Result. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Remarks. 


Incision  into  anterior  surface 
of  kidney  near  hilum.  Re- 
covered with  a  sinus  1  inch 
to  1£  sinch  long,  not  com- 
municating with  the  kidney. 
Wt.  of  calculus,  31  grains. 

( V.  Trans,  of  Clin.  Soc,  Vol.  14, 
1881.) 

Incision  into  ant.  and  lower 
part  of  kidney.  No  sinus. 
Wt.  of  calculus,  89i  grains. 

(  V.  Trans,  of  Clin.  Soc,  Vol.  18.) 


No    sinus.      Wt.    of     calculus, 

23^-  grains. 
( V.  Trans,  of  Clin.  Soc,  Vol.  20.) 

Calculus  removed  from  pelvis. 
Wt.  of  calculus,  213  grains. 
No  sinus.  Nephrotomy  and 
nephrectomy  ten  years  after 
for  recurrent  calculus. 

( V.  Table  II,  No.  43,  and  Table 
III.,  No.  13.) 

Incision  into  ant.  aspect  of 
kidney.  No  sinus.  Wt.  of 
calculus,  109  grains. 


One  large  stone  and  7  fragments 
removed.  Total  weight  of  cal- 
culus, 1,303  grains.  Urinary 
sinus  followed.  Subsequent 
left  nephrolithotomy,  1890, 
and  right  nephrectomy,  1891. 

( V.  Table  I,  No.  9,  and  Table 
III,  No.  7.) 

Three  calculi  removed  from 
kidney.  Wt.  of  calculi,  69 
grains.     No  sinus. 


160 


GASES    OF   NEPHROLITHOTOMY.— TABLE  I. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


10 


11 


12 


13 


14 


F.  J.       Male 


K.  V 


A.  P.  A. 


E.  J.  S. 


J.J 


J.  A. 


F.  H. 


Female. 


Male. 


Male. 


Male. 


Male. 


Male. 


23 


22 


40 


34 


35 


26 


48 


Pain  on  right  side.  Hsema- 
turia.  Passed  blood  in 
urine  when  a  child,  and 
had  had  pain  for  10  years. 


Pain  in  left  loin  very  severe. 


Pain  and  tenderness  in  left 
loin  for  more  than  20 
years. 


Pain  in  left  loin  for  2  years. 
Hsematuria,  pyuria,  and 
oxalate  of  lime  crystals. 


Pain  and  swelling  in  right 
loin  for  1  year.  Hsema- 
turia  and  pyuria. 


Pain  and  tenderness  in  left 
loin  and  hematuria  for 
2  years. 

Pain  in  left  loin  for  5  years, 
and  hematuria  on  three 
occasions  3  or  4  years-ago, 
but  not  since.  Frequent 
severe  colic  during  last  4 
months.  Pain  shooting 
into  left  groin. 


TABLE    L— CASES    OF   NEPHROLITHOTOMY. 


161 


Date  of    Operation. 


Result. 


Remarks. 


Feb.  23rd,  1890,  R.  Kidney. 


Apr.  23rd,  1890,  L.  Kidney. 


June  7th,  1890,  L  Kidney. 
Aug.  29th,  1890,  L.  Kidney. 

Feb.  11th,  1891,  R.  Kidney. 

Apr.  29th,  1891,  L.  Kidney. 
May  9th,  1891,  L.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Incision  into  ant.  aspect.  Three 
branched  calculi  were  re- 
moved from  the  renal  sub- 
stance, and  a  much  larger 
one  from  the  pelvis.  Total 
wt.,  200  grains.  Recovered 
without  a  sinus. 

Incision  into  pelvis  of  kidney. 

Wt.  of  calculus,  513  grains. 

Sinus      present,      but      not 

urinary  sinus. 
(For  previous  nephrolithotomy, 

v.  Table  L,  No.  6 ;  and  for 

subsequent  nephrectomy,  v. 

Table  III.,  No.  7.) 

An  oxalate  of  lime  calculus  was 
removed  from  the  cortical 
part  of  the  kidney.  Wt.  of 
calculus,  62  grains.  No 
sinus  remained. 

Incision  into  ant.  aspect,  and 
stone  found  lying  in  the 
kidney  substance  close  to 
the  pelvis.  Wt.,  129  grains. 
No  sinus  remained. 

Incision  into  ant.  aspect  and 
extraction  of  a  stone.  No 
sinus.  Wt.  of  calculus,  27^ 
grains. 

Incision  into  ant.  surface  near 
hilum.  No  sinus.  Wt.  of 
calculus,  34  grains. 


Died     May      The  patient  was  a  very  stout 
13th,  man,   and   the  kidney  very 

with     symp-  difficult  to  reach  through  an 

toms  of  urse-  oblique    wound     12     inches 

mia  and    in-  long,  joined  by  a  vertical  in- 

tense mental  cision  3  inches  long.     Brisk 

agitation.  haemorrhage  followed   renal 

i  incision,  but  was  soon  stopped 
by  pressure.  Two  stones  were  removed.  P.M. 
wound  in  left  kidney  1|  inch  long.  Left  kidney 
weighed  7^  ounces,  and  was  fatty.  Right 
kidney,  5 J  ounces,  fatty,  as  were  also  the  liver 
and  the  heart.  Small  branch  of  renal  vein 
divided  and  plugged  by  recent  clot.  No  injury 
to  peritoneum.     Wt.  of  calculi,  19i  grains. 


162 


CASES    OF   NEPHROLITHOTOMY.— TABLE    I. 


Yeae. 

No. 

Initials. 

Sex. 

Age. 

Leading  Symptoms. 

1892 

15 

J.  L. 

Male. 

35 

Pain  in  left  loin,  radiating  to 
scrotum.  Haematuria.  Fre- 
quent micturition.    Symp- 
toms 1  year. 

1892 

16 

Mrs.  R. 

Female. 

35 

Attacks  of  pain  and  frequent 

.      (P) 

micturition.      Hematuria 
for  7  years.     Pain  in  right 
side  and  occasionally  in  left. 

1892 

17 

Mrs.  N. 

Female. 

25 

Pain  for  2  months  and  sup- 

(P) 

pression  of  urine  from  left 
kidney.       In    November, 
1891,   a  calculus   was   re- 
moved    from     the     right 
(pyonephrotic)  kidney  by 
another  surgeon.     A  large 
abscess  followed,  and  this 
was  succeeded  by  a  sinus. 
The  urine  from  right  kidney 
was    discharged    through 
the  loin  by  the  old  nephro- 
tomy sinus. 

1893 

18 

W.  W. 

Male. 

13 

Pain     in     right    side    for    7 

(P) 

years.      Albuminuria  and 
occasional  hematuria.  . 

1893 

19 

Mrs.  F. 

Female. 

35 

Pain  and  tenderness  in  right 

(p) 

renal    region    for    4   or   5 
months.    Pain  on  micturi- 
tion, necessitating  a  vesico- 
vaginal fistula  for  10  years. 

1893 

20 

Mr.  Y. 

Male. 

38- 

Had  been  operated  upon   in 

(P) 

February,  1 893,  for  apeTrrre^ 
phric  abscess  on  left  side. 
This   re-formed   and    was 
opened  on  June  10,  1893. 
A  sinus  followed.     In  No- 
vember, 1892,  and  at  both 
the    above  -  named   dates, 
there  was  marked  anuria. 

TABLE    L— CASES    OF   NEPHROLITHOTOMY. 


163 


Date  of  Operation. 


Result. 


Remarks. 


Jan.  3rd,  1892,  L.  Kidney. 


July  13th,  1892,  R.  Kidney. 


Dec.  24th,  1892,  L.  Kidney. 


May  13th,  1893,  R.  Kidney. 


May  14th,  1893,  R,  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


June  29th,  1893,  L.  Kidney 


Recovered. 


Incision  into  convex  border  of 
kidney.  No  sinus.  Wt.  of 
calculus,  18  grains. 


Calculus    weighed    362    grains. 
No  sinus. 


Left  kidney  drawn  on  to  loin 
and  incised  in  three  places. 
Twenty-two  phosphatic  cal- 
culi were  removed.  Wt.  of 
calculi,  96  grains.  An  abscess 
followed,  but  on  January  9th 
wound  closed  and  was  never 
afterwards  reopened.  All 
attempts  to  close  sinus  on 
right  side  followed  by  severe 
symptoms,  requiring  sinus  to 
be  reopened.  A  cannula 
was  therefore  at  length  per- 
manently maintained  on  the 
right  side. 

(V.  Table  II.,  Nos.  13  and  14.) 

Tuberculated  heart-shaped  stone 
removed  from  pelvis  of  kid- 
ney. Wt.  33  grains.  No  sinus. 

A  small  lozenge-shaped  uric- 
acid  calculus  removed. 
No  sinus.  After  operation, 
all  painful  micturition  dis- 
appeared, and  vesico-vaginal 
fistula  was  closed  by  opera- 
tion. Wt.  of  calculus,  4  grains. 

Three  calculi  removed.  The 
kidney  was  small  and  some- 
what hydronephrotic.  In 
this  case  an  abdominal  inci- 
sion was  made  as  well  as  the 
lumbar.  Only  a  few  ounces 
of  urine  passed  by  urethra  till 
operation  wound  began  to 
close.  On  July  1 1th  1 1  ounces 
were  voided  naturally,  and 
from  this  time  the  quantity 
gradually  increased.  Wt.  of 
calculi,  17  grains.  No  sinus 
remained. 


16<i 


CASES    OF   NEPHROLITHOTOMY.— TABLE    I. 


Yeak. 


1893 


1894 
(P) 


1894 
(P) 


1894 


1895 


1895 


1896 


1896 
(P) 


No. 

Initials. 

Sex. 

Age. 

21 

J.  A. 

Male. 

21 

22 

Mrs.  B. 

Female. 

35 

23 

L.  W. 

Male. 

49 

24 

A.  C. 

Female. 

22 

25 

G.  P. 

Male. 

30 

26 

H.  G. 

Male. 

11 

27 

R.  H. 

Male. 

20 

28 

Miss  B. 

Female. 

18 

Leading  Symptoms. 


Pain  in  right  loin  for  1  year. 
Hasmaturia,  albuminuria, 
and  pyuria. 


Lumbar  pain  on  left  side. 
Pyuria  with  very  high  tem- 
perature, and  nervous  agi- 
tation. Hard  irregular 
swelling  in  right  loin,  to 
which  no  symptoms  had 
been  referred,  and  which 
was  not  known  by  patient 
to  exist. 

Previous  passage  of  many 
calculi — the  first  20  years 
ago,  the  last  in  January, 
1894.  Pain  in  left  loin. 
Pyuria  and  hsematuria,  and 
also  ova  of  Bilharzia  hsema- 
tobia. 


Pain  and  resistance  in  right 
loin  for  1  year.  Albu- 
minuria, pyuria,  and 
hsematuria.  Oxalic  and 
uric  acid  crystals. 

Pain  in  right  loin  for  4  years. 
Hsematuria  and  albu- 
minuria.    Oxalate  of  lime 


crystals. 


Pain  in  right  loin.  Hsema- 
turia and  pyuria.  Duration 
of  symptoms  3  years. 


Pain  in  left  loin  for  4  years 
Occasional  hsematuria. 


Pain  in  left  loin.  Hsema- 
turia. Symptoms  since 
twelfth  year  of  age. 


TABLE    L— CASES    OF   NEPHROLITHOTOMY. 


165 


Date  of  Opeeation. 


Result. 


Remaeks. 


Sep.  27th,  1893,  R.  Kidney. 


May   17th,  1894  (1st  op.), 
R.  Kidney. 


Recovered. 


Recovered. 


May  29th,  1894,  L.  Kidney. 


Recovered. 


Aug.  20th,  1894,  R.  Kidney. 


Jan.  2nd,  1895,  R.  Kidney. 


Oct.  11th,  1895,  R.  Kidney. 


Mar.  3rd,  189G,  L.  Kidney. 


Mar.  15th,  1896,  L.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Incision  made  into  the  organ 
and  a  stone  extracted.  Wt. 
of  calculus,  40  grains.  No 
sinus  remained. 

A  large  calculus  removed, 
weighing  830  grains,  which 
was  closely  enveloped  by  the 
dilated  pelvis  and  upper  end 
of  ureter.  Urinary  sinus  per- 
sisted. Subsequently  nephro- 
tomy was  performed  on  both 
kidneys. 

(V.  Table  II.,  Nos.  23  and  27.) 

An  incision  in  the  loin  9  inches 
long  joined  by  a  vertical 
incision  1|  inch  long.  Inci- 
sion into  convex  border  of 
kidney,  and  a  uric-acid  cal- 
culus, weighing  35j  grains, 
extracted  from  the  lower 
fourth.     No  sinus. 

Incision  into  convex  border,  and 
a  calculus  extracted  weighing 
5  grains.  Incision  in  kidney 
closed  with  catgut  sutures. 
No  sinus. 

Incision  into  pelvis  and  ureter. 
Stone  impacted  at  entrance 
of  ureter ;  removed  through 
incision  in  renal  pelvis.  No 
sutures.  No  sinus.  Wt.  of 
calculus,  6  grains. 

Incision  into  pelvis  of  kidney, 
which  was  closed  by  silk 
sutures.  Stone  size  of  small 
plum-stone  extracted.  No 
sinus.  Wt.  of  calculus,  8  grns. 

Incision  into  pelvis  of  kidney. 
Stone  size  of  hazel  nut  ex- 
tracted. No  sinus.  Wt.  of 
calculus,  25  grains. 

Calculus  removed  through  the 
front  of  the  renal  pelvis. 
The  incision  was  sutured. 
No  sinus.  Wt.  of  calculus, 
25  grains. 


166 


CASES    OF   NEPHROLITHOTOMY.— TABLE    I. 


Year. 


1896 
(P) 


No. 


29 


189} 


1891 


189"; 


30 


31 


32 


1897 
(P) 


1898 


34 


Initials. 


Mr.  M. 


R.  A. 


M.  H. 


L.  F. 


Mr.  L. 


E.  P. 


Sex. 


Male. 


Male. 


Female. 


Female. 


Male. 


Female. 


Age. 


58 


48 


29 


44 


26 


Leading  Symptoms. 


Pain  in  left  loin.  Hema- 
turia. Periodic  attacks 
every  6  months  for  8  years. 
During  last  2  years  attacks 
much  more  frequent.  For 
several  weeks  preceding 
operation  hematuria  con- 
stant. 

Pain  in  right  loin  for  40  years. 
Albuminuria,  pyuria,  and 
oxalate  crystals. 


Pain  in  left  loin  for  16  years. 


Pain  and  swelling  in  right 
loin  for  6  months.  Hgema- 
turia,  pyuria,  and  albu- 
minuria. 


Repeated  attacks  of  pain  and 
tenderness  on  left  side 
for  16  years.  Occasional 
hsematuria.  An  abiding 
aching  aggravated  by  exer- 
cise. No  pus  ;  no  crystals 
in  urine. 

Pains  in  left  loin  for  2  years. 
Repeated  attacks  of  left 
renal  colic,  accompanied 
by  temporary  complete 
suppression  of  urine,  which 
lasted  for  2  or  3  days^&tj^ 
time.  There  was  enlarge- 
ment of  rightkidney,which 
was  also  believed  to  con- 
tain a  stone,  but  to  which 
no  symptoms  were  re- 
ferred. During  attacks  of 
pain  a  swelling  is  felt  in 
left  renal  region. 


TABLE    I.— CASES    OF   NEPHROLITHOTOMY. 


167 


Date  of  Operation. 


Eesult. 


Remarks. 


Aug.  1st,  1896,  L.  Kidney. 


July  28th,  1897,  R.  Kidney. 


July  28th,  1897,  L.  Kidney. 


Nov.  22nd,  1897,  R.  Kidney. 


Dec.  18th,  1897,  L.  Kidney. 


Jan.  26th,  1898,  L.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Incision  into  posterior  aspect 
of  renal  pelvis.  Oxalate  of 
lime  calculus  removed  weigh- 
ing 41  grains.  No  sutures 
were  used  for  the  pelvis.  No 
sinus. 


Incision  into  the  ant.  aspect  of 
kidney,  and  a  stone  removed 
from  its  lower  part.  No  sinus. 
Wt.  of  calculus,  147  grains. 

Incision  into  pelvis  and  a  stone 
extracted.  The  renal  wound 
was  sutured  with  4  fine  cat- 
gut sutures.  No  sinus.  Wt. 
of  calculus,  35  grains. 

Incision  into  post,  wall  of 
pelvis,  and  a  friable,  irregu- 
larly shaped  stone  was  re- 
moved. Wound  in  pelvis 
was  sutured.  No  sinus.  Wt. 
of  calculus,  2  grains. 

Calculus  removed  from  upper 
end  of  ureter  by  an  inci- 
sion through  post,  surface  of 
pelvis.  No  sutures  used,  as 
the  tissue  of  renal  pelvis  was 
verysoft.  No  sinus  remained. 
Wt.  of  calculus,  17  grains. 

Kidney  large  and  congested. 
An  incision  was  made  in  the 
convex  border,  and  through 
it  a  stone  weighing  11  grains 
was  extracted  from  the  renal 
pelvis.  Uninterrupted  re- 
covery. No  sinus.  To  return 
for  purpose  of  having  right 
kidney  explored. 

(Postscript.— A  large  calculus 
was  removed  from  the  right 
kidney  in  April,  1898.  A 
good  recovery  without  a 
fistula  followed.) 


TABLE    II.— CASES    OF 

PERFORMED  BT 


Year. 


No. 

Initials. 

Sex. 

Age. 

1 

P.  B. 

F'emal  e. 

40 

2 

Mr.  E. 

Male. 

36 

3 

Mr.  D. 

Male. 

39 

4 

Mr.  D. 

Male. 

39 

5 

J.J. 

Male. 

64 

6 

M.  W. 

Female. 

55 

Leading  Symptoms. 


1886 


1887 
(?) 


1887 
(P) 


1887 
(P) 


1888 


1889 


Typhoid  fever,  followed  2^ 
years  after  by  an  abscess, 
which  8  months  later  was 
opened.  A  sinus  in  right 
loin  left.  Later  a  swelling 
developed,  with  pain, 
haematuria,  pyuria,  and 
oxalate  of  lime  crystals. 
Micturition  every  half 
hour. 

Pain  and  tenderness  on  left 
side.  Haematuria  after 
exertion  for  10  years  past. 


Pain  and  swelling  in  right 
loin.  Pyuria  and  haema- 
turia 12  or  14  years  ;  symp- 
toms getting  much  worse 
of  late.  Often  sounded 
for  stone  in  bladder. 


Evidence  of  stone  by  prob- 
ing previous  nephrotomy 
wound. 


Pain  in  right  loin  for  6  years. 
Haematuria  and  oxalate  of 
lime  crystals. 


Pain,  tenderness,  and  swelling 
in  right  loin.  Pyuria  and 
haematuria.  Symptoms 
for  30  years. 


NEPHROTOMY    FOR    STONE. 

MR.    HENRY  3t ORRIS. 


Date  of  Opekation. 


June  18th,  1886,  R.  Kidney. 
Large  amount  of  pus 
and  gritty  phosphatic 
calculous  material  re- 
moved. 


Jan.  22nd,  1887. 


Aug  2nd,  1887,  E,  Kidney. 


Sep.  3rd,  1887,  R.  Kidney. 


Dec.  5th,  1888,  R.  Kidney. 


May  29th,  1889,  R.  Kidney. 


Result. 


Died  June 

22nd, 
from  suppres- 
sion of  urine. 
Both  kidneys 

affected. 


Recovered. 


Recovered. 


Recovered. 


Recovered 
from  opera- 
tion, but  died 
on  Dec.  22nd 
in  a  fit,  with 
symptoms  of 
apoplexy. 


Recovered. 


Remaeks. 


More  than  200  small  facetted 
calculi,  and  a  pus-containing 
cyst,  as  well  as  interstitial 
nephritis,  were  found  in  the 
opposite  kidney.  Retroperi- 
toneal inflammation  extended 
across  the  spine  from  one 
kidney  to  the  other. 

(  V.  Trans,  of  Clin.  Soc,  Vol.  20, 
p.  106.) 

Kidney  small  and  hydro- 
nephrotic.  Angular  calculus 
removed.  Wt.,  15  grains. 
No  sinus. 

Kidney  pyonephrotic.  Small 
oxalate  calculus  removed 
through  renal  parenchyma. 
Wt.,  26  grains. 

(A  second  nephrotomy  on  same 
side  was  performed  a  month 
later,  v.  No.  4.  Sinus,  but 
not  urinary,  persisted  for 
some  years.) 

Calcium  phosphate  calculus, 
weighing  360  grains,  removed. 
Recovery  with  sinus. 

(For    previous    nephrotomy,  v. 

No.  3.) 

Extensive  atheroma  of  cerebral 
arteries.      Wt.    of    calculus, . 
71  grains. 


Several  calculi  removed.     Total 
wt.,  500  grains.     No  sinus. 


170       GASES    OF   NEPHROTOMY  FOB    STONE.— TABLE    II. 


Year. 


1889 


1889 
(P) 


1889 
(P) 


1890 
(P) 


1891 


1892 


No. 

Initcals. 

Sex. 

Age. 

i 

H.  F.  P. 

Female. 

20 

8 

St.  A. 

Female. 

47 

9 

Mrs.  G. 

Female. 

48 

.       10 

Mr.  A. 

Male. 

45 

11 

W.  T. 

Male. 

17 

12 

W.  0. 

Male. 

33 

Leading  Symptoms. 


Pain  and  tenderness  in  right 
lumbar  region.  Hsema- 
turia  and  pyuria.  Fre- 
quency of  micturition. 
Symptoms  for  18  months. 

{V.  Brit.  Med.  Joum.,  1892, 
Vol.  1,  p.  1066.) 


Pain  and  perinephritic  abscess 
on  right  side.  Pyuria  and 
hseinaturia  for  4  years. 
Pyonephrosis  for  several 
months.  Perinephritic  ab- 
scess pointing  over  lower 
ribs.     Profuse  diarrhoea. 


Pain,  tenderness,  and  enlarge- 
ment of  kidney  on  right 
side.  Pyuria.  Symptoms 
going  on  for  4  years. 


Pain  and  tumour  in  right  side. 
Pyuria.  Symptoms  for 
several  years. 


Pain  and  tenderness  in  right 
loin.  Previous  pas^age__of 
a  stone.  Hsematuria  and 
pyuria.  Symptoms  for  10 
years. 


Pain  and  tenderness  in  right 
loin  for  1  year.     Pyuria. 


TABLE   IL— CASES    OF   NEPHROTOMY   FOR    STONE.       171 


Date  of  Operation. 


July  27th,  1889,  R.  Kidney. 


Aug.  11th,  1889,  R.  Kidney. 


July  8th,  1889,  R.  Kidney. 


Dec.  17th,  1890,  R.  Kidney. 


Dec.  2nd,  1891,  R.  Kidney. 


Mar.  22nd,  1892,  R.  Kidney. 


Result. 


Recovered. 


Died       Aug. 

12_th. 
Septicaemia 

before 
operation. 


Recovered. 


Died  Jan. 
26th, 1891. 
Septicaemia 
after  opera- 
tion, due  to 
pre-existing 
condition  of 
kidney. 

Died       Dec. 

4th. 

Calculous 

disease  of 

opposite 

kidney. 


Recovered. 


Remarks. 


Two  calculi  and  large  amount 
of  pus  removed.  Wt.  of 
calculi,  3h  and  84  grains.  In 
1890  patient  complained  of 
pain  in  the  left  loin.  Lapar- 
otomy was  performed  and 
both  kidneys  examined.  No 
further  disease  found.  Pa- 
tient quite  relieved  of  her 
symptoms. 
(F.  Table  4,  No.  16.) 

The  patient  was  in  extmnis, 
and  the  operation  was  per- 
formed as  a  last  possibility 
of  saving  her  life.  Tissue 
round  kidney  very  dense 
and  fibrous.  Kidney  con- 
tained a  quantity  of  thick 
pus  and  a  calculus  weighing 
30  grains.  No  P.M.  Death 
18  hours  after  operation. 

Cavity  in  kidney  containing  pus 
and  large  amount  of  soft  phos- 
phatic  concretions  weighing 
about  30  grains.  Recovery 
with  a  sinus,  which  eventu- 
ally closed. 

Kidney  contained  a  number  of 
abscesses  and  a  calculus 
weighing  125  grains.  Died 
with  symptoms  of  septic- 
aemia. External  wound 
apparently  aseptic. 


Incision  into  convex  border  of 
kidney.  Three  small  calculi 
and  a  large  amount  of  pus 
found.  Passed  very  little 
urine  after  operation,  and 
after  death  the  left  kidney 
Avas  found  to  be  extensively 
diseased  with  a  stone  im- 
pacted in  the  ureter.  Wt. 
of  calculi,  40  grains. 

Kidney  purulent,  with  2  calculi 
weighing  57i  grains.  Recov- 
ered with  a  temporary  sinus. 


172       GASES    OF   NEPHROTOMY   FOR    STONE.— TABLE    II. 


Year. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1892 
(p) 


1892 
(P) 


13 


14 


Mrs.  N. 


Mrs.  N. 


Female. 


Female. 


25 


25 


1892 


15 


c.  c. 


Female. 


36 


1892 


16 


J.  M. 


Male. 


45 


1893 


E.  E, 


Female. 


35 


1893 


18 


T.  E. 


Male. 


53 


An  abscess  following  a 
nephrotomy  for  calculus 
clone  by  another  surgeon  in 
November,  1891. 


Nephrotomy  for  abscess  fol- 
lowing previous  neph- 
rotomy for  calculus. 


Frevious  passage  of  2  stones. 
Pain  in  both  loins,  chiefly 
left.  Pyuria,  hsematuria, 
and  albuminuria.  Swell- 
ing in  left  loin.  Symptoms 
for  2  years. 

Discharging  sinus  in  left  loin, 
following  perinephritic  ab- 
scess in  i 889-90.  An  injury 
from  falling  with  his  left 
loin  against  a  cask  in  1862 
was  succeeded  by  inter- 
mittent hsematuria  extend- 
ing over  a  period  of  1  year. 


Pain  and  movable  tumour  in 
right  loin.  Albuminuria, 
hsematuria,  and  pyuria. 
Symptoms  for  15  years. 


Pain  and  swelling  in  right 
loin.  Hsematuria  and 
pyuria.  Symptoms  (pain 
and  hsematuria)  off  and  on 
for  40  years.  Tumour  in 
side  for  12  months. 


TABLE    II.— GASES    OF   NEPHROTOMY   FOR    STONE.        173 


Date  of  Opeeation. 


Result. 


Remarks. 


July  5th,  1892,  R.  Kidney. 


Sep.  8th,  1892,  R.  Kidney. 


July  5th,  1892,  L.  Kidney. 


Aug.  8th,  1892,  L.  Kidney. 


Feb.  10th,  1893,  R.  Kidney. 


Feb.  14th,  1893,  R,  Kidney. 


Recovered.       A  third  nephrotomy  was  per- 
formed   on  right  kidney  on 
Sep.  8th.  Pus  and  phosphatic 
grit  removed. 
(V.  Table  II.,  No.  14.) 

Recovered.  This  was  the  third  nephrotomy 
on  right  kidney.  Pus  and 
phosphatic  grit  removed. 
(For  second,  v.  Table  II., 
No.  13.)  Subsequent  nephro- 
lithotomy on  left  kidney. 
( V.  Nephrolithotomy,  v.  Table  I., 
No.  17.) 

Recovered.  Large  quantity  of  pus  evacuated. 
Calculi  weighing  534  grains. 
Recovered  with  a  small  sinus, 
which  subsequently  healed. 


Recovered.  Sinus  explored,  and  a  calculus 
found  just  outside  the  kidney 
substance.  Wt.  of  calculus, 
3  grains.  The  sinus  event- 
ually completely  healed  for 
a  time,  and  he  remained 
quite  well  till  a  fresh  abscess, 
followed  by  a  sinus,  occurred, 
and  he  returned  for  further 
treatment  in  June,  1895. 
( V.  Table  II.,  No.  26.) 

Died        Feb.     The  kidney  was  loculated.    Four 

11th,  calculi  removed  :  2  small  and 

from  uraemia.  another  large  calculus  from 

Atrophy  of  left         kidney    substance,    and    1, 

kidney  also.  size  of  marble,  from  pelvis. 

Wt.   of   calculi,    208   grains. 

Only  a  few  ounces  of  urine 
were  passed.  P.M.,  no  injury  to  peritoneum. 
Left  kidney  anaemic,  small.  Renal  substance 
of  right  kidney  largely  atrophied;  strong- 
fibrous  septa  between  calyces. 


Recovered. 


There  were  2  large  cystic  swell 
ings  in  the  kidney.  Three 
stones  were  extracted :  1 
from  the  pelvis,  90  oz.  of 
fluid  came  from  the  cysts 
Recovery  without  a  sinus 
Wt.  of  calculi,  208  grains. 


174       GASES    OF   NEPHROTOMY   FOB    STONE.— TABLE   II. 


Yeak. 

No. 

Initials. 

Sex. 

Age. 

Lealing  Symptoms. 

1893 

19 

Mrs.  C. 

Female. 

63 

Attacks  of  pain  in  right  loin, 

(P) 

accompanied   by   suppres- 
sion, of   urine,    for    three 
months.      Suppression    of 
urine   for    5    days   before 
operation.     Two  years  ago 
passed  a  stone,  but  it  was 
not    known     from    which 
kidney.         Asthma     and 
bronchitis     at     time      of 
operation. 

1894 

20 

Mr.  W. 

Male. 

61 

Nephrotomy    on    account   of 

(P) 

fistula    following    a    peri- 
nephritic   abscess    opened 
7   months   before.      Much 
pus  in  urine. 

1894 

21 

W.  C. 

Male. 

33 

Pain  chiefly  in  right  side  and 

(P) 

passage  of  calculi.   Heema- 
turia  and  pyuria.     Dura- 
tion of  symptoms  4  years. 

1894 

22 

Mrs.  P. 

Female. 

23 

Pain  in   right  lumbar  region 

(P) 

and  pyuria  for  four  years. 
Two  months  ago,  pain  and 
rigors.     A  large,  movable, 
smooth   tumour   in    right 
renal  region. 

1894 

23 

Mrs.  B. 

Female. 

35 

Troublesome   sinus    on   right 

(p) 

kidney  and    suspicion    of 
stone  in  ureter.     Nephro- 
lithotomy had  been    per- 
formed on  this  kidney  in 
May,  1894. 

TABLE    II.— GASES    OF   NEPHROTOMY   FOR    STONE.       175 


Date  of  Operation. 


Result. 


Remarks. 


Oct.  6th,  1893,  It.  Kidney. 


Aug.  4th,  1894,  R.  Kidney. 


Aug.  21st,  1894,  R.  Kidney. 


Dec.  12th,  1894,  R.  Kidney. 


Died        Oct. 

6th,  1893, 
of  anuria  and 

bronchitis. 


Died       Aug. 
6th,  1894, 
of  anuria. 


Died       Aug. 

23rd,   1894, 

from  cerebral 

thrombosis 

occurring 

during 
anaesthesia. 


Recovered. 


Nov.  28th,  1894  (2nd  op.), 
R.  Kidney. 


Recovered. 


Incision  into  convex  border  of 
kidney.  One  calculus  and 
several  phosphatic  concre- 
tions in  pelvis  and  upper  end 
of  ureter.  Died  an  hour 
after  operation.  Wt.  of  cal- 
culus, 18  grains. 


Pus  and  calculus  removed  ;  one 
calculus  and  several  small 
pieces.  Perinephritic  tissue 
very  dense  and  bound  to 
kidney.  Death  from  sup- 
pression of  urine.  Wt.  of 
calculi,  36  grains. 

Five  calculi  removed.  The 
largest  was  wedged  in  the 
pelvis.  Wt.,  177  grains. 
When  effects  of  anaesthetic 
had  passed  off  he  was  found 
to  be  aphasic  and  hemi- 
plegic  on  right  side.  P.M., 
extensive  thrombosis  of  left 
middle  cerebral.  Fatty  and 
dilated  heart.  Stones  in  left 
kidney. 

Kidney  sacculated  and  con- 
tained pus.  A  calculus  was 
extracted  from  the  pelvis 
through  an  incision  in  the 
convex  border  of  the  kid- 
ney. Recovered  without  a 
sinus.  Wt.  of.  calculus,  13 
grains. 

Two  small  calculi  removed  from 
upper  end  of  right  ureter. 
Wt.  of  calculi,  10  grains. 
After  this  operation,  the 
symptoms  made  it  probable 
that  the  left  kidney  was  not 
excreting  any  urine.  The 
left  kidney  was  subsequently 
operated  on — v.  Table  II., 
No.  27. 

(For  first  operation  in  the  right 
kidney,  v.  Table  I,  No.  24.) 


176        CASES    OF    NEPHROTOMY   FOB    STONE.— TABLE    II. 


Yeae. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms 


1894 


1895 


24 


25 


1895 


1895 
(P) 


26 


E.  J.  B. 


H.  W. 


J.  M. 


Male. 


34 


Male. 


Male. 


Mrs.  B. 


28 


47 


Female. 


35 


Stones  removed  from  bladder 
in  1872  when  12  years  of 
age,  and  others  since  have 
passed  through  the  peri- 
neal fistula,  which  fol- 
lowed lithotomy.  Pain, 
tenderness,  and  resistance 
in  left  loin.  Pyuria,  album- 
inuria, and  haematuria. 
Symptoms  for  26  years, 
commencing  when  8  years 
old,  continuous  for  last  two 
years. 

Pain  and  tenderness  and  swell- 
ing in  right  loin  for  5  weeks. 
Hematuria,  pyuria,  and 
albuminuria.  Pain  in  left 
loin  for  years.  Stones  re- 
moved from  left  kidney  at 
St.  Thomas's  Hospital  1\ 
years  ago. 

Two  sinuses  in  left  loin.  Pre- 
vious nephrotomy  for  cal- 
culus in  1892.  Pyuria  and 
albuminuria.  Formerly 
injury  to  left  loin,  followed 
by  hematuria. 


Incomplete  and  intermittent 
suppression  for  18  days. 
Complete  suppresstoirVf- 
urine  for  4  days  and 
tumour  in  left  loin.  Great 
collapse. 


TABLE    II.— CASKS    OF   NEPHROTOMY   FOE    STONE.        177 


Date  of  Operation. 


Feb.  20th,  1894,  L.  Kidney,  i     Recovered. 


Apr.  1st,  1895,  R.  Kidney. 


June  25th,  1895,  a  lumbar 
sinus  laid  open. 

June  28th,  1895,  examina- 
tion of  kidneys  by 
laparotomy. 


Feb.   8th,   1895  (3rd   op.), 
L.  Kidney. 


M 


Recovered. 


Died      June 

28th. 

Both  kidneys 

diseased. 


Rejiaeks. 


Several  ounces  of  foul  greenish 
pus  in  sacculated  kidney. 
Uric-acid  stone,  weighing  19 
grains,  found  in  orifice  of 
ureter.  Incision  into  ant. 
aspect  of  kidney  and  pus 
and  calculus  removed.  Re- 
covery with  a  sinus. 

(For  subsequent  nephrectomy, 
v.  Table  III,  No.  10.) 


Incision  into  ant.  aspect  of  kid- 
ney. Kidney  contained  pus, 
and  a  uric-acid  stone  with 
some  phosphatic  deposit  was 
found  in  pelvis.  Discharged 
with  a  small  sinus,  which 
was  gradually  diminishing. 
Wt.  of  calculus,  132  grains. 


Sinus  explored  on  June  25th, 
but  as  the  tissues  were  very 
dense,  the  kidney  could  not 
be  distinguished.  Severe 
pain  continuing,  and  urine 
being  almost  suppressed, 
laparotomy  was  performed  and  both  kid- 
neys examined  on  June  28th,  but  no  stone 
felt.  P.M.,  left  calculous  pyelitis,  with 
branched  calculi  within,  with  complete  de- 
struction of  kidney  substance  and  2  fistulous 
openings  between  left  renal  pelvis  and 
descending  colon.  Chronic  nephritis  of  right 
kidney.      (See  Table  II.,  No.  16.) 


Died       Feb. 

8th,  1895, 

from  anuria. 

Both  kidneys 

extensively 

disorganised 

by  calculi. 


The  patient  was  in  a  very  col- 
lapsed condition,  and  the 
operation  was  performed  as 
the  only  remaining  chance 
of  prolonging  life.  Large 
quantity  of  foetid  pus.  Stone 
impacted  in  orifice  of  ureter, 
and  another  large  branched 
calculus  at  upper  end  of 
kidney.  Death  2  hours 
after  operation.  Wt.  of 
calculus,  224  grains.  _ 

(For  previous  operations  on 
right  kidney,  v.  Table  I.,  No. 
24;  Table  II.,  No.  23.) 


178        CASES    OF   NEPHROTOMY   FOR    STONE.— TABLE    II. 


Yeae. 


1895 
(P) 


1895 

to 


1895 
(P) 


1896 
(P) 


1896 
(P) 


1896 


No.      ;  Initials,  i      Sex. 


28      I    L.  C.       Male. 


29 


30 


31 


32 


33 


c.  c. 


G.  H. 


W.  H. 


Capt,  M 


D.I. 


Male. 


Male. 


Male. 


Male. 


Male. 


Age. 


50 


38 


49 


56 


45 


Leading  Symptoms. 


Pain  and  large  tumour  in  left 
loin.  Profuse  pyuria.  Ill 
many  years,  and  desper- 
ately ill  on  arrival  in  Lon- 
don. Had  lieen  advised 
throughout  by  London 
physician  against  any 
operation,  but  now  com- 
pelled, as  he  "  can't  go  on 
any  longer." 

Intermittent  pain  in  right 
kidney  for  many  years. 
Many  calculi  passed,  and 
the  right  kidney  was 
several  times  blocked.  Dis- 
tinct tumour. 


Occasional  pyuria  with  left- 
sided  "  lump  "  since  1878, 
both  persistent  since  1894. 
Pain  in  left  loin.  High  tem- 
perature. Pyuria  ceased 
and  lump  increased  during 
last  3  weeks.  Penal  cal- 
culus diagnosed  in  1882. 
Syphilitic  hemiplegia  4 
years  ago. 

Pyuria  since  1870.  Repeatedly 
treated  for  cystitis.  Hema- 
turia after  exercise  in  1893. 
Since  1894  pain  and  swell- 
ing in  right  loin. 


A  history  for  many  years  of 
calculus.  Rapid  enlarge- 
ment of  right  kidney^after 
a  day's  hunting  on  a  restive 
horse. 


Pain  in  right  loin  for  12  years. 
Hsematuria,  pyuria,  and 
albuminuria. 


TABLE    TL— CASES    OF   NEPHROTOMY    FOR    STONE.       179 


Date  of  Operation. 


Aug.  1st,  1895,  L.  Kidney. 


Feb.  6th,  1895,  R.  Kidney. 


Result. 


Died       Aug. 

5th,  from 

exhaustion 

and  uraemia. 


Nov.  2nd,   1895   (1st  op.), 
L.  Kidney. 


Nov.  20th,  1896,  E.  Kidney. 


Feb.  21st,  1896,  E.  Kidney. 


Nov.  20 fch,  1896,  E.  Kidney. 


Eecovered. 


Eecovered, 
but  sinus 
continued. 


Eecovered. 


Eecovered. 


Eecovered. 


Remarks. 


A  calculus  removed  weighing 
248  grains.  The  kidney  con- 
tained quantities  of  very 
offensive  pus.  Symptoms  of 
uraemia  supervened,  with  dis- 
charge of  moderate  quantity 
of  highly  albuminous  urine, 
and  patient  died.     No  P.M. 


Kidney  in  advanced  state  of 
pyonephrosis.  One  very 
large  calculus  and  3  small 
ones,  welded  together  by 
phosphatic  material,  were 
removed.  Eecovery  without 
a  sinus.  Wt.  of  calculi, 
920  grains. 

Kidney  large  and  contained  pus. 

Calculus  removed  weighing 

122  grains. 
(Subsequent     nephrectomy,    v. 

Table  III.,  No.  12.) 


Large  stone  extracted  weighing 
591  grains.  Kidney  sub- 
stance contained  a  large 
amount  of  very  thick  cheesy 
pus.  Eecovered  without  a 
sinus. 

Kidney  full  of  blood.  Stone 
weighing  260  grains  tightly 
impacted  in  lower  part  of 
pelvis.  Kidney  very  hydro- 
nephrotic.  Eecovered  with- 
out a  fistula  ;  subsequently  a 
small  superficial  sinus  fol- 
lowed a  fresh  infra-renal  hae- 
morrhage, induced  by  heavy 
gun  practice  on  board  ship. 

Stone  in  kidney  substance  close 
to  hilum,  weighing  591 
grains.  Kidney  contained 
pus.    No  sinus. 


180       GASES    OF   NEPHROTOMY   FOB    STONE.— TABLE    II. 


Year. 


1896 
(P) 


No.      i  Initials.       Sex 


1896 
(P) 


1896 


1897 
(P) 


1897 


1897 


35 


Mrs.  O.    Female. 


S.  S. 


Male. 


36 


F.  C. 


37 


Mr.  J. 


38 


39 


F.I. 


A.  M. 


Male. 


Male. 


Male. 


Female. 


Age. 


47 


21 


37 


41 


31 


35 


Leading  Symptoms. 


Pain  in  right  renal  region. 
Hsematuria  first  when  24 
years  old  after  riding.  Fre- 
quent micturition.  Pyuria 
and  albuminuria  since  14 
years  ago.  Has  been  fre- 
quently treated  for  cystitis. 


Intermittent  pain  in  left 
side.  Hematuria.  Pyuria. 
Symptoms  of  5  to  6  years' 
duration.     Xo  tumour. 


Penal  abscess  opened  at  St. 
Peter's  Hosp.  in  1894 ; 
and  right  kidney  explored 
there  in  1895,  but  no  stone 
found.  In  1896,  six  small 
stones  were  passed.  Albu- 
minuria and  pyuria. 

Pains  and  signs  of  calculus 
on  right  side  for  11  years. 
Operation  for  pyonephro- 
sis by  another  surgeon  in 
1895.  Two  sinuses  com- 
municated with  the  kid- 
ney :  one  between  8th  and 
9th  ribs,  and  the  other  in 
ilio-costal  space — the  site 
of  the  former  operation. 


Pain    and 
loin, 
pyuria, 
attacks 
years. 


swelling  in  right 
Hematuria  and 
Occasional  slight 
of    pain    for   12 


Pain  and  swelling  in  left  loin 
for  18  months.  Pyuria, 
hematuria,  and  albu- 
minuria. 


TABLE    II.— CASES    OF   NEPHROTOMY   FOB    STONE.       181 


Date  of  Operation. 


Result. 


Remake*. 


Dec.  2nd,  1896,  E.  Kidney. 


Dec.  14th,  1896,  L.  Kidney. 


Dec.  2nd,  1896,  11.  Kidney. 


Jan.  17th,  1897,  II.  Kidney. 


Feb.  8th,  1897,  R.  Kidney. 


Mar.  19th,  1897,  L.  Kidney. 


Recovered.  A  spiculated  calculus,  size  of  a 
small  marble,  was  removed 
from  pelvis.  Incision  into 
post,  aspect  of  pelvis  was 
closed  by  3  Lembert's  su- 
tures. The  kidney  was  sac- 
culated. Recovery  without 
a  sinus.  Wt.  of  calculus, 
17  grains. 

Recovered.  Seven  calculi,  occupying  dis- 
tinct sacculated  recesses, 
were  removed.  Kidney 
small,  with  great  loss  of 
medullary  substance.  Re- 
covery without  a  sinus.  Wt. 
of  calculi,  168  grains. 

Recovered.  Three  stones  were  found.  Re- 
covery with  sinus.  This  sinus 
has  since  quite  closed.  Wt. 
of  calculus,  49  grains. 


Recovered.  Fistulainloin  laid  open.  Twelfth 
rib  excised.  One  large  cal- 
culus and  9  fragments  the 
size  of  cherry  stones  were 
removed  from  two  distinct 
recesses  in  the  right  kidney. 
Sinus  in  loin  closed  for  a 
time,  but  subsequently  re- 
opened ;  that  between  the 
ribs  still  persisted.  Wt.  of 
calculi,  107  grains.   Removal 

of  parts    of   9th,   10th,   and    11th   ribs,   with 

view  of  getting  sinus  to  close,  on  Feb.  18th. 

Result  promising,  but  as  yet  undetermined. 
{Note.— August,  1898.     The  fistulse  have  quite 
healed  and  the  patient  is  cured.) 


Recovered. 


Recovered. 


Incision  into  post,  aspect  of 
kidney  near  hilum.  3  calculi 
found,  weighing  380  grains. 
No  sinus.  Kidney  loculated 
and  much  degenerated. 

Stone  found  in  pelvis  of  kidney, 
weighing  141  grains.  Kidney 
substance  was  much  hollowed 
out.    No  sinus. 


182       CASES    OF   NEPHROTOMY   FOB    STONE.— TABLE    II. 


Year. 


1897 


1897 
(P) 


1897 


1897 
(P) 


1897 


No. 


40 


41 


42 


43 


44 


Initials. 


W.  Pv. 


Mrs.  B. 


C.  B. 


Mr:  H. 


W.  W. 


Sex. 


Male. 


Female. 


Female. 


Male. 


Male. 


Age. 


22 


47 


2G 


34 


31 


Leadixg  Symptoms. 


Pain  in  right  side  occasionally 
nearly  all  his  life.  Pyuria, 
haematuria,  and  albu- 
minuria. 


Pain,  swelling,  and  mobility 
of  right  kidney.  Pyuria. 
From  3  to  4  years  aching 
in  right  kidney.  No  hema- 
turia throughout ;  but 
urine  often  thick  and 
offensive. 


Pain  in  right  side  for  3 
months.  Albuminuria, 
haematuria,  and  pyuria. 


Perinephritic  abscess  on  left 
side.  Nephrolithotomy  on 
kidney   of    same   side    in 

1887. 


A  negative   exploration  was 
performed  on  March  26th, 

1890,  on  account  of  pain 
and  haematuria  of  one 
year's  duration.     In  June, 

1891,  he  passed  a  small 
stone.  Remained  quite 
well  for  18  months,  when 
intense  pain  and  haema- 
turia occurred.  Three 
weeks  before  readmission 
he  passed  another  stone. 


TABLE    II.— GASES    OF  NEPHROTOMY  FOE    STOXE.       183 


Date  of  Operation. 


Result. 


Rejiaeks. 


Apr.  14th,  1897,  R.  Kidney. 


Recovered. 


Apr.  3rd,  1897,  R.  Kidney. 


Oct.  ]3th,  1897,  R.  Kidney. 


Oct.  24th,  1897,  L.  Kidney. 


Dec.  6th,  1897,  R.  Kidney 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Incision  into  ant.  aspect  of 
kidney.  A  stone  removed 
from  the  kidney  substance. 
Considerable  hydronephrosis 
of  the  kidney.  No  sinus. 
Wt.  of  calculus  30j  grains. 

Kidney  enlarged  and  pyone- 
phrotic.  Two  calculi :  1  in 
pelvis  and  other  in  upper 
end  of  ureter.  These  calculi 
were  in  contact  with  each 
other,  and  had  highly 
polished  surfaces,  and 
weighed  826  grains.  Re- 
covery without  a  sinus. 

The  kidney  was  cystic,  and  on 
being  tapped,  4oz.  of  purulent 
fluid  escaped.  Two  stones 
were  found  in  the  calyces. 
No  sinus.  Wt.  of  calculi, 
18  grains. 

Kidney  found  to  be  much 
sacculated,  and  a  large  stone 
removed  weighing  240  grains. 

(For  previous  nephrolithotomy 
v.  Table  I.,  No.  4,  and  for 
subsequent  nephrectomy,  v. 
Table  III.,  No.  13.) 

The  kidney  was  hypertrophied 
and  the  pelvis  very  dilated. 
Incision  into  post,  wall  of 
pelvis  allowed  a  considerable 
quantity  of  fluid  to  escape.  A 
large  calculus  was  found  in 
the  renal  pelvis  and  removed 
through  an  incision  in  the 
pelvis ;  another  calculus  in 
the  ureter  about  4  inches 
down.  The  ureter  was  in- 
cised, stone  extracted,  and 
the  incision  in  the  ureter 
sutured.  The  wound  in  the 
pelvis  was  also  sutured.  No 
sinus.  Wt.  of  calculi,  117 
grains. 

( V.  Table  IV.,  No.  17.) 


TABLE    III.— CASES     OF 

PERFORMED     BY 


Yeae. 


1883 


No. 


Initials.  >      Sex. 


Age. 


1890 


1890 


1890 


R.  W. 


C.  L. 


L.  A. 


Male. 


Female, 


Male. 


W.  P.       Male. 


33 


44 


38 


30 


Leading  Symptoms. 


Entirely  disabled  by  pain  and 
tenderness  in  right  loin. 
Passage  of  stones.  Hsema- 
turia  and  albuminuria. 


Pain  and  large  swelling  in 
right  loin.  Pyuria.  Symp- 
toms for  10  years. 


Pain  for  6  years.  Previous 
passage  of  2  stones  2  years 
ago  and  2  months  ago  re- 
spectively. Frequent  mic- 
turition. Pain  in  both 
loins,  chiefly  in  left. 
Pyuria, 


Swelling  and  pain  in  right 
loin.  Pyuria.  Symptoms 
for  9  years. 

{Brit.  JJed.  Journ.,  Vol.  1, 
1893,  p.  4.) 


NEPHRECTOMY     FOR    STONE. 

MR.     HENRY    MORRIS. 


Date  of  Operation. 


Oct.  24th,  1883,  R.  Kidney. 


July  16th,  1890,  R.  Kidney. 


Oct.  23rd,  1890,  L.  Kidney. 


Nov.  1 2th,  1890,  R.  Kidney, 


Result. 


Remakes. 


Recovered.  Previous  negative  exploration 
in  1882.  No  sinus.  Kidney 
quite  healthy  to  naked  eye 
but  for  presence  of  stone. 
Wt.  of  calculus,  about  20 
grains. 
(See  Roy.  Med.-Chir.  Soc.  Trans., 
1885,  Vol.  8,  and  Table  IV., 
No.  2.) 

Recovered.  Kidney  in  advanced  state  of 
pyonephrosis.  A  large 
crumbling  calculus  extracted, 
weighing  557  grains.  Re- 
covery with  a  small  sinus. 
(Brit,  Med,  Journ.,  1893,  Vol.  1, 
p.  4.) 

Died  Oct.        The   left  kidney  weighed  over 
25th.  2g-  ounces,   and    was    in     a 

Interstitial  state  of  chronic  interstitial 

nephritis  of  nephritis,  and  contained  cysts 

opposite  filled  with  calculous  material, 

kidney.  Urine  was  freely  passed  after 

operation,  and  after  feeling 
drowsy  for  a  few  hours,  pa- 
tient suddenly  collapsed  and  died.  P.M., 
wound  healthy.  No  injury  to  peritoneum  or 
surrounding  structures.  Uric-acid  calculus 
impacted  in  left  ureter  2 in.  from  bladder. 
Right  kidney  small.  Interstitial  nephritis. 
(Brit.  Med.  Journ.,  1892,  Vol.  1,  p.  1065  ; 
and  Brit.  Med,  Journ.,  1893,  Vol.  1, 
p.  4.) 


Died  Nov. 

16th. 

Pyonephrosis 

and  calculus 

in  opposite 

kidney. 


The  kidney  was  converted  into 
a  pyonephrotic  sac — with 
calculi  weighing  441  grains. 
Urrne  was  freely  passed  after 
operation,  but  patient  gradu- 
ally sank  and  died.  P.M., 
wound  healthy.  No  injury 
to  peritoneum  or  other  struc- 
tures. The  left  kidney  was 
found  to  be  in  a  very  ad- 
vanced state  of  pyonephrosis, 
and  also  contained  calculi. 


186     OASES    OF   NEPHRECTOMY   FOB    STONE. -TABLE    III. 


Year. 

Xo. 

Initials. 

Sex. 

Age. 

Leading  Symptoms. 

1890 
(P) 

5 

Mrs.  D. 

Female. 

26 

Pain    and     tumour    in    loin. 
Pyuria. 

1891 

6 

J.  D. 

Female. 

23 

Pain,  tenderness,  and  swelling 
in  left  loin  for  9  months. 
Pyuria  and  albuminuria. 

1891 

7 

K.  V. 

Female. 

23 

Troublesome  sinus  and  renal 
destruction      from     fresh 
calculus,      after     nephro- 
lithotomy of  right  kidney. 

1892 

8 

J.  A. 

Male. 

47 

Attacks  of  renal  colic  for  12 
years.     Pain  and  tumour 
in  left  loin.     Hematuria 
and  pyuria. 

1893 
(P) 

9 

A.  T. 

Male. 

22 

Aching  in  right  loin.  Attacks 
of  pyrexia.  Pyuria.  Symp- 
toms 3  to  4  years. 

1894 

10 

E.  J.  B. 

Male. 

34 

Pyonephrosis  with  persisting 
sinus  after  nephrotomy. 

1894 
'(P) 

11 

Capt.E. 

Male. 

48 

Very  large  tumour  in   right 
lumbar  region.   Symptoms 
of  renal  calculus  wiieiLJL 
boy.       Attacks    of    pain, 
with  hsematuria,  in  1877, 
1880,  1885,  and  1894. 

TABJjE    TIL— GASES    OF   NEPHRECTOMY    FOR    STONE.     187 


Date  or  Operation. 


Result. 


April  20,  1890. 


Recovered. 


June  10th,  1891,  L.  Kidney.        Recovered. 


July  25th,  1891,  R,  Kidnej 


Aug.  29th,  1892,  L.  Kidney. 


Feb.  22nd,  1893,  R,  Kidney. 


Mar.  27th,  1894,  L.  Kidney. 
Nov.  19th,  1894,  R.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Remarks. 


Three  calculi  were  found,  weigh- 
ing 58|-  grains.  Kidney  in 
advanced  state  of  pyone- 
phrosis.    No  sinus. 

The  kidney  substance  contained 
10  oz.  of  very  offensive  pus, 
and  2  calculi  were  found  lying 
at  the  mouth  of  the  ureter. 
Wt.  of  calculi,  23  grains. 

The  kidney  was  in  a  state  of 
pyonephrosis,  and  contained 
calculous  concretions.  Good 
recovery  without  a  sinus. 
In  this  case  nephrolithotomy 
had  been  previously  per- 
formed on  both  kidneys. 

(For  previous  operations,  v.  Table 
I.,  Nos.  6  and  9  ;  Brit.  Med. 
Joum.,  1893,  Vol.  1,  p.  4.) 

The  kidney  was  extremely 
sacculated,  and  the  ureter 
much  dilated.    No  sinus. 


The  right  kidney  was  very  small 
and  strongly  adherent  to  sur- 
rounding tissue.  The  organ 
was  sacculated,  and  con- 
tained a  small  phosphatic  cal- 
culus. Sinus  for  few  months; 
ultimately  quite  healed. 

(For  previous  nephrotomy,  v. 
Table  II.,  No.  24.) 


Died  Nov.        Operation  performed  when  pa- 
19th,  tient  was  in  extreme  condi- 

from  shock.  tion    and    supposed    to    be 

Hopelessly  ill  suffering     from     malignant 

at  time  of  disease  of   liver.      Tumour, 

operation,  which       simulated     malig- 

which  was  nant  disease,  was  first   ex- 

done  as  plored  by   laparotomy,  and 

giving  the  then    exposed    by    incision 

only  chance,  j  through  loin.  10  oz.  of  cal- 
culus and  large  amount  of 
disorganised  blood-clot  re- 
moved from  kidney.  Haemorrhage  severe,  so  that 
nephrectomy  was  performed.  Patient  died  1\ 
hours  after  completion  of  operation. 


188     CASES    OF   NEPHRECTOMY   FOB    STOXE.— TABLE    III. 


Year.  No.        Initials.       Sex.  Age 


189.-) 

IP) 


1897 
(P) 


189^ 


1891 


1898 
(P) 


12 


13 


14 


15 


16 


Mr. 

G.  H. 


Mr.  H. 


E.  B. 


F.  B. 


Mr.  P. 


Male. 


Male. 


Female. 


Male. 


Male. 


49 


34 


50 


34 


51 


Leading  Symptoms?. 


Pyonephrosis  and  persistence 
of  fistula  after  nephrotomy. 
Opposite  kidney  had  been 
secreting  well  up  to  time 
of  operation. 


Persisting   sinus   after   neph- 
rotomy. 


Acute  pain  in  left  loin. 
Pyuria.  Attacks  of  pain 
for  20  years. 


Pain  and  resistance  in  left 
loin.  Hematuria  and 
pyuria.  Blood  first  noticed 
in  urine  when  he  was  9 
years  old. 


Attacks  of  left-sided  colic  for 
23  years  with  occasional 
hematuria  —  one  serious 
attack  lasting  several 
weeks.  Pyuria  and,  finally, 
a  perinephritic  abscess, 
which  was  opened  Oct. 
3rd,  1897,  and  followed  by 
a  sinus. 


TABLE    III.— CASES    OF   NEPHRECTOMY    FOR    STONE.     189 


Date  oe  Operation. 


Result. 


Remarks. 


Dec.  19th,  1895,  L.  Kidney. 


Dec.  29th,  1897,  L.  Kidney. 


;  Died       Dec. 

22nd. 
1  Death     from 

anuria. 


Recovered. 


Feb.  5th,  1897,  L.  Kidney. 


Recovered. 


July  30th,  1897,  L.  Kidney. 


Feb.  3rd,  1898,  L.  Kidney 


Died    Aug. 

16th. 

Calculus 

almost 

certainly  in 

opposite 

kidney,  but 

no  P.M. 

allowed. 


Recovered  from  the 
effects  of  opera- 
tion, and  was  con- 
valescing well, 
when  he  expired 
suddenly  on  Feb.  17th  from  heart 
failure  after  receiving  sudden 
alarming  news.  He  had  previously 
had  severe  attacks  of  syncope,  and 
on  some  occasions,  Dr.  Cliaffey, 
of  Brighton,  tells  me,  these  attacks 
had  been  like  angina. 


Death  due  to  suppression  of 
urine.  Previous  nephrotomy 
for  calculus.  Had  had  syphi- 
litic hemiplegia,  and  still 
had  remains  of  gumma  in 
calf  of  leg. 

(F.  Table  II,  Xo.  30.) 

Kidney  found  to  be  a  mere 
shell.  It  was  very  firmly 
fixed  to  surrounding  tissues. 
Wt.  of  calculus,  14  grains. 

(For  two  previous  operations,  v. 
Table  I.,  No.  4,  and  Table 
II.,  No.  43.) 

No  sinus.  The  kidney  was 
greatly  altered,  and  its  sub- 
stance hollowed  out.  A 
small  calculus  was  found 
firmly  embedded  in  the 
wall  of  ureter,  close  to 
its  commencement.  This 
stone  projected  into  the 
lumen,  and  the  ureter  was 
dilated  above.  A  little  be- 
low was  a  much  smaller 
stone,  also  embedded  in 
wall  of  ureter. 

The  left  kidney  was  in  an  ad- 
vanced stage  of  pyonephro- 
sis, and  a  calculus  was  found 
completely  blocking  the  up- 
per end  of  left  ureter.  After 
the  nephrectomy,  the  urine 
still  contained  the  same 
amount  of  pus  and  blood, 
thus  conclusively  showing 
that  the  remaining  kidney 
was  also  the  seat  of  pyo- 
nephrosis. No  P.M.  exam, 
could  be  obtained. 

The  kidney  was  very  sacculated, 
and  its  secreting  substance 
almost  destroyed,  except  a 
small  portion  in  the  infe- 
rior part.  The  kidney  con- 
tained a  large  stone,  weigh- 
ing 172  grains. 


190     GASES    OF   NEPHRECTOMY   FOR    STONE.— TABLE    III. 


Year. 


1898 


No. 


1898 


18 


Initials. 


Mr.  T. 

(p) 


M.  L. 


Sex. 


Age. 


Male. 


Male. 


53 


58 


Leading  Symptoms. 


Occasional  severe  attacks  of 
renal  (left)  colic  _  with 
hematuria  and  pyuria,  ex- 
tending over  several  years. 
Calculi  had  been  passed. 


Attacks  of  pain  in  left  loin 
30  years  ago  which  en- 
tirely passed  off.  In  No- 
vember, 1897,  there  was 
pain  in  left  loin  of  a  dull 
character,  with  very  acute 
exacerbations.  Tender- 
ness in  left  loin,  but  no 
tumour.  Urine  contained 
albumen  and  pus,  but  no 
blood. 


TABLE    III.— CASES    OF   NEPHRECTOMY    FOR    STONE.     191 


Date  of  Operation. 


•Result. 


Remarks. 


Feb.  14th,   1898, 
Nephrectomy,  L.  Kidney. 


March  4th,  1898, 
Nephrectomy,  L.  Kidney. 


Recovered. 


Recovered. 


Stout  thick-set  man.  A  long, 
oblique,  lumbar  incision. 
The  last  rib  had  to  be  re- 
moved. Evidence  of  intense 
chronic  perinephritis.  Kid- 
ney greatly  disorganised. 
Ureter  patent  but  inflamed. 
No  stone  present  at  time  of 
operation. 

The  kidney,  which  was  situated 
very  high  up  under  the  lower 
ribs,  was  in  an  advanced 
stage  of  pyonephrosis,  and 
contained  a  calculus  weigh- 
ing 2-I8  grains. 


TABLE    IV.— EXPLOR- 

TERFORMED    BY 


Yeab. 


No.        Initials.       Sex, 


Age. 


Leading  Symptoms. 


1882 


1  J.  G.        Male 


1882 


35 


P.  W 


1885 


1886 


1886  5 


A.F. 


E.  S. 


G.  M. 


Male. 


34 


Female. 


Male. 


29 


30 


Male. 


58 


Symptoms  over  11  years.  Pus 
in  urine.  Pricking  pain 
and  tenderness  in  left  loin. 


Paroxysmal  pain  in  right  loin 
for  10  months.  Passed  a 
calculus  the  size  of  a  pea. 

(Referred  to  in  Brit.  Med. 
Journ.,  Vol.  1,  1892,  p. 
1067.) 


Pain  and  frequency  of  micturi- 
tion for  6  years.  Albumin- 
uria, pyuria,  and  haema- 
turia. 


Occasional  attacks  of  hema- 
turia for  7  years.  Fre- 
quency of  micturition. 
Tenderness  in  left  loin  and 
some  pyuria. 


Was  treated  for  renal  calculus 
in  1874,  and  passed  some 
stones.  Pain  in  left  loin. 
Pyuria  and  albuminuria. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1009.) 


ATORY    OPERATIONS. 

MR.    HENRY  MORRIS. 


Date  of  Operation. 


Result. 


Remarks. 


Jan.  4th,  1882,  L.  Kidney. 


Recovered. 


Nov.  8th,  1882,  R.  Kidney. 

Subsequent  nephrectomy 
on  Oct.  24th,  1883, 
when  a  stone  was  found 
embedded  inthekidney. 


July  25th,  1885,  L.  Kidney. 


Dec.  1st,  1886,  L.  Kidney. 


Recovered, 
with   relief. 


Recovered. 


Recovered. 


April  14th,  1886,  L.  Kidney. 


Recovered. 
No  relief 
followed 
operation. 


No  stone  felt  in  kidney.  Large 
trocar  and  cannula  passed  in 
at  the  convex  border,  but  no 
fluid  withdrawn.  Wound 
healed  without  sinus.  Kidney 
was  movable  on  psoas. 

(See  Brit.  Med.  Joum.,  1892, 
Vol.  1,  p.  1009.) 

(For  subsequent  operation,  v. 
No.  28.) 

The  lower  part  of  the  kidney 
was  very  firm  and  hard  to 
the  touch,  but  exploration 
with  finger  and  a  needle 
failed  to  reveal  a  stone. 
Wound  healed,  and  pain  less 
than  before  operation. 

(See  Table  III.,  No.  1.) 

Kidney  carefully  felt  with  finger 
and  probed  in  several  places 
with  negative  result.  Some 
heematuria    persisted.       No 

sinus. 

Exploration  of  kidney  with 
finger  and  needle.  Negative 
result.  No  sinus.  Prostatic 
abscess  subsequently  opened. 
Probably  tuberculous. 

(V.  Brit.  Med.  Joum.,  1892, 
Vol.  1,  p.  1009.) 

Kidney  felt  with  finger  and 
explored  with  probe.  Patient 
died  from  other  causes  on 
June  19th.  P.M.— Prostatic 
calculus,  cystitis,  commenc- 
ing pyonephrosis  on  left 
side,  and  on  the  right  the 
kidney  was  shrivelled  and 
the  ureter  3  inches  from  in- 
fundibulum  was  converted 
into  a  fibrous  cord. 


194 


EXPLORATORY    OPERATIONS.— TABLE    IV. 


Yeab. 


No.        Initials. 


1888 


1888 


1889 


Mr.  S. 
(P) 


Sex. 


Male. 


Mr.  C 
(P) 


C.  W. 


M.  C. 


Male. 


Male. 


Female. 


Age. 


63 


56 


34 


51 


Leading  Symptoms. 


Great  pain  in  left  hypochon- 
driac region  for  3  years. 
Pyuria.  Rigors  at  inter- 
vals. Kidney  very  movable, 
and  gave  patient  impres- 
sion of  something  swing- 
ing "  like  a  pendulum." 


Attacks  of  renal  colic  on  left 
side  since  May,  1886.  Py- 
uria since  Oct.,  1887.  On 
Feb.  3rd,  while  on  a  long 
journey,  was  seized  with 
great  pain  and  alarming 
collapse,  followed  by  an- 
uria for  26  hours. 

(Referred  to  in  Brit.  Med. 
Journ.,  Vol.  1,  1892,  p. 
1067,  under  "  Undetected 
renal  calculus.") 


Paroxysmal  pain  in  right  loin, 
with  pain  and  difficulty  in 
micturition,  with  vomiting 
for  3  years.  On  one  oc- 
casionhsematuria.  Oxalate 
of  lime  crystals  in  urine. 
For  5  months  preceding 
operation  pains  had  been 
much  worse  and  shooting 
along  the  abdomen  into 
testis. 

Tenderness  and  pain  in  right 
loin,  following  injury  to 
back  3  years  before.  Oc- 
casional hematuria  and 
pyuria. 

{V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1008.) 


TABLE    IV.— EXPLORATORY    OPERATIONS. 


195 


Date  of  Opeeation. 


June  6th,  1887,  L.  Kidney. 


Feb.  25th,  1888,  L.  Kidney. 


Dec,  19th,  1888. 


Mar.  4,  1889,  K.  Kidney. 


Result. 


Recovered. 

Symptoms 

not  relieved. 


Recovered. 


Recovered. 


Recovered. 


Remakes. 


The  kidney  was  found  to  be 
somewhat  movable,  but 
otherwise  nothing  was  found. 
More  than  a  year  afterwards 
the  patient  died,  and  at  the 
RM.  a  calculus  was  found 
in  the  bladder  end  of  ureter  ; 
the  prostate  was  riddled  with 
abscesses,  and  both  kidneys 
were  the  seat  of  suppura- 
tion. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1065.) 

The  left  kidney  was  found  to 
be  movable.  The  pelvis 
was  palpated  from  the  front. 
The  renal  cavity  was 
pouched  and  dilated,  but 
there  was  a  considerable 
thickness  of  renal  sub- 
stance. Wound  healed 
well.  Pyuria  continued  for 
many  months  afterwards. 
Presumption  a  stone  had 
passed,  or  was  in  vesical 
end  of  ureter,  or  in  calyx 
of  kidney. 

Kidney  thoroughly  explored 
with  finger,  a  needle,  and 
trocar  and  cannula.  Kidney 
moved  in  "cinder-sifting" 
manner.  A  little  puriform 
urine  escaped  through  the 
cannula,  but  no  stone  could 
be  felt.  Nephropexy  by 
author's  method. 

{V.   Brit.    Med,    Journ.,    1892, 
Vol.  1,  p.  1009.) 

Kidney  palpated  and  punctured 
with  exploring  needle  and 
trocar  and  cannula.  Old 
perinephritis.  The  perine- 
phritic  tissue  was  very  dense 
and  matted  together,  giving 
the  impression  that  the 
kidney  was  enlarged.  Re- 
covered without  a  sinus. 
Known  to  be  well  in 
1892. 


196 


EXPLORATORY   OPERATIONS.— TABLE   IV. 


Year. 


1889 


No. 


Initials. 


10 


1889 


11 


12 


A.  B. 


Mr.  A. 
(p) 


Sex. 


Age. 


Male. 


Male. 


20 


21 


Leading  Symptoms. 


M.  C.     Female. 


1890 


1890 


13 


14 


Mr.  F. 
(?) 


Mr.  B. 
(?) 


Male. 


Male. 


51 


37 


35 


Dull  aching  pain  in  left  loin 
for  9  months.  Albu- 
minuria, pyuria,  and 
crystals  of  oxalate  of  lime. 

(Referred  to  in  Brit.  Med. 
Journ.,  Vol.  1,  p.  1067, 
under  "  No  sufficient  cause 
discovered.") 

Hagmaturia  first  in  May,  1888, 
after  sprain  at  lawn  tennis, 
then  at  intervals  up  to 
March,  1889,  when  it  be- 
came continuous.  During 
an  attack  in  1888  the  kid- 
ney swelled  up,  and  was 
apparently  blocked  by 
blood-clot  for  a  time. 
Urine  examined  for  tuber- 
cle bacilli,  but  none  found. 
Tuberculous  family  history 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1007.) 


Injury  to  back  in  1886,  when 
carrying  a  water-bucket. 
Since  then  has  had  occa- 
sional pain  in  back,  espe- 
cially on  right  side.  Small 
amount  of  blood  in  urine. 


Symptoms  of  renal  calculus. 
Oxaluria,  for  which  he  had 
been  treated  for  6  months. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1065.) 

Pains  in  region  of  right 
kidney,  coining  oii^yvElTsT 
roughing  it  in  diamond 
fields  in  Africa. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1008.) 


TABLE   IV.— EXPLORATORY    OPERATIONS. 


197 


Date  of  Operation. 


Aug.  29th,  1889,  L.  Kidney. 


May  3rd,  1889,  L.  Kidney. 


March  4th,  1889.  R.  Kidney. 


April  30th,  1890,  R.  Kidney 


Aug.  26th,  1890,  R.  Kidney. 


Result. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Remarks. 


Negative  exploration  of  left 
kidney.  Wound  healed.  After 
leaving,  an  abscess  developed 
in  the  right  loin,  and  a 
tubercular  deposit  formed  in 
the  epididymis.  No  sinus. 
Protably  tuberculous. 

The  kidney  was  freely  punc- 
tured, but  not  incised.  Old 
■perinephritis.  The  perine- 
phritic  tissue  was  very  ad- 
herent, and  the  upper  part 
of  the  kidney  was  harder 
than  normal.  Possibly  due 
to  old  injury.  Hematuria 
occurred  during  convales- 
cence, and  also  at  intervals 
for  a  short  time  afterwards, 
and  then  ceased  altogether. 
No  sinus.  He  has  been  well 
since,  is  married,  and  leads  an 
active  life.   Was  seen  in  1897. 

Kidney  small  and  closely  matted 
to  adjacent  tissue.  Explored 
with  finger,  needle,  and  trocar 
and  cannula,  but  no  stone  or 
pus  found.  Old,  perine- 
phritis.    No  sinus. 

(V.  Brit.    Med.  Jour?i.,   Vol.  1 
1892,  p.  1008.) 


Kidney  moved  in  "  cinder-sifting "  man- 
ner. The  convex  border  of  the  kidney- 
was  incised  and  the  organ  explored.  A 
sacculated  calyx,  covered  with  only  a  thin  layer  of  renal  tissue 
in  upper  part  of  organ,  was  found.  The  incision  in  the  kidney 
was  sutured.  Two  calculi,  which  must  have  been  in  the  ureter, 
were  passed  during  convalescence. 


Recovered. 


The  kidney  was  explored  and 
punctured,  but  not  incised. 
Old  perinephritis.  The  peri- 
nephritic  tissue  was  dense 
and  very  adherent  to  the 
kidney.  The  wound  healed, 
but  after  hard  exercise  (shoot- 
ing in  Scotland)  an  abscess 
formed  and  was  opened  on 
Nov.  6th.  It  soon  healed, 
and  he  left  Southampton  on 
Nov.  28th,  1890.  Has  kept 
well  since,  and  led  a  very 
active  life  in  South  Africa. 


198 


EXPLORATORY   OPERATIONS.— TABLE   IV. 


Year. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1890 


15 


Mr.  W. 
(p) 


Male. 


35 


1890 


16 


H.  F.  P. 


Female. 


21 


1890 


17 


W.W. 


Male. 


24 


1890 


18 


F.  W.  B. 


Male. 


29 


Came  from  India  with  symp- 
toms of  stone.  Attacks 
of  colic.  Increasing  left- 
sided  pain  for  1  year. 
Passed  a  stone  4  months 
ago. 


Pyuria.  Previous  nephrotomy 
and  extraction  of  calculi 
from  right  kidney  on  July 
27th,  1889.  After  this 
operation  there  was  pain 
in  left  loin,  and  some  cal- 
culi were  passed  on  differ- 
ent occasions.  On  October 
23rd,  5  smooth  and  oval 
stones  were  voided,  weigh- 
ing together  4  grains. 


Aching  pain  in  the  right 
loin  for  12  months.  Occa- 
sional hematuria. 

(Referred  to  in  Brit.  Med. 
Journ.,  1892,  Vol.  1,  p. 
1067,  under :  "No  suffi- 
cient cause  discovered.") 


After  recovery  from  peri- 
tonitis in  February,  1890, 
pain  in  right  loin^for— 5- 
months,  paroxysmal  in 
character.  A  movable 
swelling  could  be  felt 
below  right  costal  margin. 


TABLE    IV.— EXPLORATORY    OPERATIONS. 


199 


Date  of  Opekation. 


April  27th,  1890,  R.  Kidney. 


Jam  17th,  1890.  Explora- 
tion through  an  ab- 
dominal incision. 


Mar.  26th,  1890,  R.  Kidney. 


June  18th,  1890,  R.  Kidney. 


Result. 


Recovered 

from  operation, 

but  died 

almost 

suddenly  from 

haemorrhage 

due  to  gastric 

ulcer  about 

one  month 

afterwards. 


Recovered. 


Recovered. 


Remakes. 


The  right  kidney  was  incised 
along  convex  border  and 
freely  explored.  Nothing 
was  found,  and  it  was  sutured. 
Wound  healed.  On  May  24th 
patient  died  after  profuse 
haeinatemesis,  and  at  P.M. 
examination  an  ulcer  of  the 
stomach  was  found  almost 
perforating. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  897.) 

The  right  kidney,  which  had 
been  previously  operated 
upon,  was  rather  soft  and 
flabby  at  its  upper  end,  but 
otherwise  normal.  The  left 
was  of  very  soft  consistence. 
In  1894  was  living  and  well, 
and  had  given  birth  to  one 
child. 

(For  previous  nephrotomy,  v. 
Table  II.,  No.  7.  Brit.  Med, 
Jozir?i.,  1892,  Vol.  1,  p.  1066.) 

Kidney  incised  and  finger  passed 
into  renal  pelvis  ;  calyces 
dilated,  but  no  stone  found. 
Wound  healed  without  a 
sinus.  In  June,  1891,  and 
again  in  November,  1897,  a 
stone  was  passed.  Ne- 
phrotomy and  ureterotomy 
for  calculus  performed  in 
December,  1897. 

(V.  Table  II.,  No.  44.) 


Recovered        The  kidney  was   exposed    and 
from  operation,         brought  up  into  the  wound, 
but  not  much  and    seen    to    have    several 

if  at  all  white   tuberculous    deposits 

relieved.  in  its  substance.     No  stone. 

Recovered  with  some  im- 
provement, and  was  dis- 
charged with  wound  quite 
healed  ;  but  shortly  after  an 
abscess,  and  then  a  faecal 
fistula,  formed  in  right  iliac  fossa,  which  was 
subsequently  found  to  be  communicating  with 
the  caecum.  Probable  primary  seat  of  disease 
was  tuberculosis  of  caecum  or  appendix. 
(V.  Brit.  Med.  Journ.,  1892,  Vol.  1,  p.  898.) 


200 


EXPLORATORY    OPERATIONS.— TABLE   IV. 


Yeae. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1891 


19 


B.  F. 


Female. 


33 


1891 


20 


1891 


21 


1892 


22 


G.  L. 


Mr.  D. 


P.  J. 


Female. 


Male. 


Male. 


37 


40 


35 


Pain  in  right  loin  of  18  months' 
duration.  Pain  sometimes 
extremely  severe,  entirely 
disabling  her.  Retention 
of  urine  for  3  weeks  before 
admission.  Pyuria,  hsema- 
turia,  and  oxalate  crystals. 
Employed  at  swimming 
baths,  and  had  probably 
had  strains  in  back. 

{V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1008.) 


Paroxysmal  pain  in  left  side 
and  vomiting.  Frequency 
of  micturition  and  occa- 
sional hsematuria.  Pyuria 
and  oxalate  of  lime  crystals 
in  urine.  Pieces  of  mortar- 
like stone  had  been  passed. 
Bladder  twice  examined 
with  negative  results. 

(V.  Brit.  Med.  Journ.,  1892, 
Vol.  1,  p.  1067.) 

Symptoms  of  renal  calculus  for 
14  years.  For  many  months 
previous  to  operation  had 
suffered  so  much  he  could 
scarcely  attend  to  his 
business.  Passed  piece  of 
calculus  in  1878,  and  two 
months  later  a  second  piece. 


Frequent  very  severe  attacks 
of  hsematuria,  Avith  great 
pain  on  right  side  since 
1886.  Frequency  of  mictu- 
rition. Large  quantity  of 
pus  in  urine. 


TABLE    IV— EXPLORATORY    OPERATIONS. 


201 


Date  of  Operation. 


April  1st,  1891,  K.  Kidney. 


May  23rd,  1891,  L.  Kidney. 
Haemorrhoids    and    rectal 

polypus      removed      5 

weeks  later. 


July  18th,  1891. 


Result. 


Recovered. 


Recovered. 


May  23rd,  1892,  R.  Kidney. 


Recovered. 


Recovered 

from 

operation, 

but  died 

June  13th 

from 

tuberculous 

disease  of 

both  lungs 

and 
left  kidney. 


Remarks. 


A  puckered  scar  was  found  in 
lower  and  outer  border  of 
kidney  and  evidence  of  old 
perinephritis,  the  result  pro- 
bably of  injury.  Incision 
into  convex  border  and  ex- 
ploration of  hilum  revealed 
nothing.  Renal  wound  was 
closed  by  fine  catgut  sutures, 
and  healed  without  a  sinus. 
Wound  healed  rapidly,  and 
she  was  discharged  on  May 
4th  convalescent  and  free 
from  pain.  Heard  of  since 
as  keeping  well. 

No  stone  felt,  but  there  was  a 
small  hard  lump  near  upper 
and  posterior  border,  which 
proved  to  be  a  retention  cyst. 
An  incision  was  made  into 
the  convex  border,  but  no 
stone  felt.  The  wound  in 
the  kidney  was  closed  with 
catgut  sutures,  and  healed 
without  a  sinus.  Was  seen 
quite  well  in  June,  1892. 

Convex  border  of  kidney  in- 
cised and  digitally  explored ; 
sutured.  Kidney  small,  renal 
pelvis  sacculated.  Perine- 
phritic  tissue  dense  and 
matted  to  kidney,  and  was 
separated  with  difficulty.  No 
stone  found.  Quite  recovered. 
No  sinus.  Heard  of  at  in- 
tervals since  as  keeping  quite 
well. 

(Brit.  Med.  Journ.,  1892,  Vol.  1, 
p.  1066.) 

Kidney  large  and  tabulated.  Incision 
made  in  convex  border,  but  no  stone 
found.  Patient  was  much  troubled 
with  hiccough,  and  before  death 
had  several  attacks  of  hEematemesis. 
Lungs  riddled  with  recent  grey 
granulations.  Traces  of  old  tuber- 
culous disease  in  both.  Also  in  right 
epididymis  and  cord.  Left  kidney 
a  multilocular  cyst  with  caseous 
contents.  Left  ureter  full  of  tuber- 
culous material.  (P.M.  Eeport,  p. 
327  ;   Surg.  Report,  1892.) 


202 


EXPLORATORY   OPERATIONS.— TABLE    IV. 


Year. 


No. 


1893 


23 


Initials. 


1894 


24 


Mrs.  S. 


Sex. 


Age. 


Female. 
(P) 


O.K. 


1894 


25 


1894 


26 


Female. 


66 


11 


L.  B.     Female. 


W.F. 


1894 


27 


E.S. 


47 


Male. 


Female. 


31 


38 


Leading  Symptoms. 


Occasional  pain  and  tender- 
ness in  left  kidney  fol- 
lowing a  strain.  General 
indisposition  and  occasion- 
ally some  marked  pyrexia. 
Much  psychical  disturb- 
ance both  before  and  after 
operation. 

Pain  in  right  loin  and  also 
during  micturition  for  3 
months.  A  few  pus  cells 
in  urine  and  some  oxalate 
crystals.  Incontinence  of 
urine. 


Nephrorrhaphy  on  right  side 
in  1892  by  provincial  sur- 
geon ;  but  kidney  becom- 
ing loose  again,  a  second 
fixation  operation  was 
performed  by  Mr.  Morris 
on  Dec.  5,  1893.  Return 
of  pain  and  nausea,  espe- 
cially after  exertion,  in 
April,  1894.  Uric-acid 
crystals  in  urine. 


Previous  exploration  through 
left  linea  semilunaris  of 
left  kidney  by  a  colonial 
surgeon.  Dragging  pain  in 
left  loin.  Swelling  in  left 
loin  and  passage  of  a  stone. 
Oxalate  crystals  in  urine. 


Pain  on  micturition  and  in 
back  for  some  _  months, 
more  marked  on  right  side. 
Pus  and  albumen  occasion- 
ally present  in  urine. 


TABLE    IV.— EXPLORATORY    OPERATIONS. 


203 


Date  of  Operation. 


Result. 


Remarks. 


Oct.  15th,  1893,  L.  Kidney. 


Feb.  20th,  1894     Eight  K. 


June  23rd,  1894.  Ex- 
ploratory laparotomy 
followed  by  incision 
into  E.  loin. 


Nov.  14th,  1894,  L.  Kidney. 


Nov.  15th,  1894,  E.  Kidney. 


Eecovered. 


Eecovered. 

Urine  still 
contained  pus 
and  oxalate  of 
lime  crystals. 


Died  June 
25th. 
Gastric  ulcer 
almost  per- 
forating in 
posterior  sur- 
face of  small 

curvature 

3  inches  from 

pylorus. 


Eecovered. 


Eecovered. 

Pain  relieved, 

but  albumen 

and  pus  still 

in  urine. 


The  kidney  was  exposed,  and 
on  dividing  the  capsule, 
two  or  three  teaspoonsful  of 
fluid  blood  escaped.  "  Sub- 
capsular haemorrhage."  Com- 
plete subsequent  recovery. 


E.  kidney  brought  to  surface 
through  a  lumbar  incision. 
Incision  along  convex  border 
and  pelvis  digitally  explored. 
Eenal  wound  closed  with  cat- 
gut sutures.  Wound  healed 
by  first  intention,  and  patient 
discharged  on  March  30, 
_  1894. 

Kidney  was  very  firmly  fixed  to 
surrounding  structure.  In- 
cision was  made  into  cortex 
and  finger  introduced  into 
pelvis,  but  no  stone  felt. 
After  operation  there  was 
most  obstinate  vomiting  and 
some  haematemesis.  P.M. 
A  gastric  ulcer  was  found. 
Kidneys  showed  fibroid 
changes.  Wounds  healthy, 
no  peritonitis. 

(For  previous  operation,  v.  Table 
V.,  No.  20.) 

Exploratory  incision.  No  ab- 
normality found.  Kidney, 
firm  and  apparently  healthy, 
was  not  incised.  Discharged 
free  from  pain ;  no  sinus. 
Seen  March  5,  1898.  Had 
been  quite  well  through 
rough  life  in  S.  Africa  since 
operation. 

Incision  made  into  convex 
border  of  kidney.  Explora- 
tion by  finger  failed  to  dis- 
cover anything  abnormal. 
Eenal  incision  closed  with  3 
catgut  sutures.  Eecovered 
without  a  sinus. 


204 


EXPLORATORY    OPERATIONS.— TABLE    IV. 


Year. 


No. 


1894 


28 


Initials. 


J.  G. 


Sex. 


Male. 


Age. 


1894 


29 


1895 


30 


1896 


1896 


31 


32 


W.  F.  S, 


J.  M. 


M.  P. 


E.  H. 


Male. 


Male. 


Female. 


Female. 


46 


47 


20 


27 


22 


Leading  Symptoms. 


Pain  in  left  loin  dating  since 
1871.  Negative  explora- 
tion of  left  kidney  in  1882, 
when  kidney  was  found 
somewhat  movable.  Pain 
in  left  loin  again  returned. 


Pain  in  1881  in  loins;  shortly 
after  passed  a  stone.  Others 
passed  in  1883  and  subse- 
quently. Pain  in  back 
since,  worse  on  left  side. 
During  1894  several  severe 
attacks  of  left-sided  colic. 
Urine  alkaline,  triple  phos- 
phate and  oxalate  crystals 
and  pus. 


Pain  in  loins  chiefly  on  right 
side.  Severe  attacks  of 
haematuria.  Symptoms 
for  6  months. 


Pain  in  loins,  chiefly  left. 
Occasional  hsematuria, 
albuminuria. 


Pain  in  both  loins,  but  mostly 
in  the  left.  Duration  5 
months.  Occasional  hema- 
turia. 


TABLE    ir— EXPLORATORY    OPERATIONS. 


205 


Date  of  Operation. 


Mav  1st,  1894,  L.  Kidney. 


Oct.  13th,  1894,  L.  Kidney. 


Result. 


Recovered. 


Remabks. 


Recovery 

with  loss 

of  all  pain. 


Feb.  2nd,  1895,  R.  Kidney. 


Nov.  11th,  1896,  L.  Kidney. 


Dec.  14th,  1896,  UKidney. 


Subsequent 

nephrectomy 

and  death 

from 

continuance  of 

hsematuria  and 

haemorrhage 

from  wound. 


Recovered. 


Recovered. 


Kidney  exposed,  and  scar  along 
convex  border  from  former 
puncture  was  found  to  be 
firm  and  slightly  vjuckered. 
An  incision  was  made  into 
kidney  through  the  scar,  and 
the  pelvis  explored  with  the 
finger,  but  no  stone  found. 
Patient  discharged  with  a 
small  sinus,  which  healed 
soon  after. 
(For  1st  operation,  v.  No.  1.) 
1898.  Seen  at  short  intervals 
up  to  present  time.  Often 
passes  large  quantities  of 
urates  and  occasionally  albu- 
men.    Has  grown  very  stout. 


Kidney  explored  through  loin. 
Incision  in  convex  border  and 
finger  passed  into  renal  pelvis. 
No  stone  ;  but  in  lower  part 
of  kidney  a  large  sacculus 
communicated  with  the  renal 
cavity.  Renal  wound  closed 
by  sutures.  Parietal  wound 
healed  rapidly  and  com- 
pletely. Was  free  from  pain 
after  operation. 


Incision  made  into  post,  border  of 
kidney,and  the  organ  explored 
with  finger,  but  no  stone  found. 
The  cortex  was  sutured.  Sub- 
sequently nephrectomy  was 
performed  on  account  of  con- 
tinuing haematuria. 

(V.  Table  VIII.,  No.  3.) 


Incision  made  into  kidney,  but 
nothing  found.  Wound 
healed  well. 


Extravasation  of  blood  found 
under  capsule.  "  Subcap- 
sular haemorrhage."  Kidney 
incised  and  explored,  but 
no  stone  felt.  Wound  com- 
pletely healed. 


206 


EXPLORATORY    OPERATIONS.— TABLE    IV. 


Year. 


1896 


No. 


33 


1896 


34 


1896 


1897 


35 


36 


Initials. 


G.  B. 


C.  E.       Male 


Sex. 


Male. 


G.  C.       Male. 


Mr.  W.  :    Male. 
(p) 


1897 


37 


1S97 


38 


H.F. 


Male. 


Age. 


21 


34 


34 


29 


24 


J.  K.    !    Male. 


42 


Leading  Symptoms. 


Pain  in  the  right  loin  for  3 
years.  Pus  occasionally  in 
the  urine. 


Dull  aching  pain  in  right 
loin  for  a  few  months. 
Urine  often  thick. 


Paroxysmal  acute  attacks  of 
pain  in  right  loin,  with 
occasional  hematuria. 


Passed  a  calculus  8  years 
before.  Later  on  he  had 
frequency  of  micturition 
and  the  bladder  was 
examined.  Pain  in  left  loin 
and  some  enlargement  of 
left  lobe  of  prostate. 


Attacks  of  pain  in  left  loin  for 
two  years.  Urine  some- 
times very  dark.  Tender- 
ness and  sense  of  resistance 
in  left  loin.   Albuminuria. 


Hsematuria  in  July,  1896, 
after  straining  his  side. 
Some  indefinite  swelling 
and  pain  in  left  loin  oc- 
curred 6  months  later  and 
continued,  as  did  also  the 
hsematuria. 


TABLE    IV.— EXPLORATORY   OPERATIONS. 


207 


Date  of  Operation. 


Mar.  5th,  1896,  R.  Kidney. 


March     25th,     1896,     R. 
Kidney. 


April  28th,  1896,  R.  Kidney. 


July  11th,  1897,  L.  Kidney. 


March     18th,      1897,     L. 
Kidney. 


April  7th,  1897,  L.  Kidney. 


Result. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Remarks. 


Incision  made  into  convex  bor- 
der of  kidney  and  finger  in- 
troduced, but  no  stone  felt. 
The  renal  incision  was  closed 
with  5  gut  sutures.  Wound 
healed  well. 

Kidney  palpated,  finger  intro- 
duced through  an  incision  in 
its  outer  border,  but  no  stone 
felt.  Wound  closed  with 
sutures.  Wound  healed 
completely,  and  the  pain  was 
relieved. 

The  kidney  was  explored  by  the 
finger  through  an  incision 
along  the  convex  border.  Pa- 
tient discharged  with  wound 
healed. 

The  kidney  was  exposed  and 
incised,  but  found  to  be  quite 
healthy  ;  sutured.  The 
bladder  was  also  sounded  and 
cystoscopecl  and  prostate  ex- 
amined under  anaesthesia. 
Wound  healed  well.  Pain 
was  relieved,  but  some  vesical 
irritability  still  remained. 
Small  prostatic  calculus  sus- 
pected. Tubercle  bacilli  had 
been  frequently  searched  for 
in  urine,  but  none  found. 

Kidney  examined  digitally 
through  an  incision  in  its. 
convex  border,  but  nothing 
found.  The  kidney  wound 
was  sutured.  Wound  healed, 
and  patient  left  with  less, 
pain  than  before. 


On  exposing  the  kidney  a  small 
stone  was  thought  to  be  felt 
in  the  pelvis.  In  separating 
the  kidney  the  cortical  sub- 
stance, which  was  very  thin, 
gave  way,  and  a  large 
quantity  of  altered  blood- 
clot  came  from  the  interior  of  the  kidney. 
"Intrarenal  hsematoma."  On  introducing  the 
finger  no  stone  could  be  felt :  v.  No.  39. 


Recovered, 

but  pain  soon 

returned. 


208 


EXPLORATORY    OPERATIONS.— TABLE    IV. 


"Year. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1897 


39 


J.K. 


Male. 


42 


1897 


40 


L.V. 


Female. 


18 


1897 


41 


M.  P. 


Female. 


45 


1897 


42 


E.  M. 


Female. 


39 


L.  kidney  previously  explored. 
Persistence  of  pain  and  oc- 
casional severe  hsematuria. 


Frequent  attacks  of  pain  in 
left  loin,  which  radiate 
down  the  left  leg.  Some- 
times pain  in  micturition. 


Frequency  of  micturition  for 
2  years,  followed  by  pain 
on  micturition,  and  some 
abdominal  pain.  Slight 
amount  of  pus  and  blood 
in  urine,  and  some  oxalate 
crystals.  Bladder  ex- 
plored, and  catheterisation 
of  ureters  showed  pus  to 
come  from  the  left. 

Aching  pain  in  back,  espe- 
cially on  right  side,  for 
some  years.  Urine  has 
occasionally  contained  pus 
and  blood. 


TABLE    IV.— EXPLORATORY    OPERATIONS. 


209 


Date  of  Operation. 


Nov. 22nd,  1897,  L.  Kidney. 


Result 


Recovered. 


June  9th,  1897,  L.  Kidney.        Recovered 


July  7th,  1897,  L.  Kidney. 


July  30th,  1897,  R.  Kidney. 


Recovered. 
Symptoms 
have  since 
returned. 


Remakes. 


Recovered. 


The  incision  was  made  through 
the  old  scar,  and  after  a 
prolonged  search  the  kidney 
was  found  to  be  represented 
by  a  flattened  mass  of  fibrous 
tissue.  The  ureter  was  very 
much  atrophied  throughout. 
Thus  the  kidney  had  com- 
pletely atrophied  between 
April  7th  and  Nov.  22nd  of 
the  same  year.  Quite  re- 
lieved of  pain,  but  heema- 
turia  continues,  and  the  man 
is  getting  gradually  weaker. 
He  died  in  June,  1898,  from 
retro  -  peritoneal  carcinoma 
and  secondary  deposits  in 
the  liver. 

(For  previous  explor.,  v.  No.  38.) 

The  kidney  appeared  to  be  nor- 
mal, and  an  incision  into  its 
substance  revealed  nothing 
abnormal.  The  kidney  sub- 
stance was  sutured,  and 
wound  healed  well.  Left 
hospital  quite  relieved. 

Partial  excision.  The  kidney 
was  found  to  be  somewhat 
granular  and  contracted. 
An  incision  showed  that 
the  cortex  was  atrophied. 
An  abscess  in  the  paren- 
chyma was  opened  and 
scraped.  No  stone  found. 
Kidney  wound  closed  with  4 
sutures.  Wound  healed  well. 

Nothing  abnormal  found.  The 
kidney  was  explored  by  an 
incision  into  its  substance, 
which  was  afterwards  closed 
by  4  silk  sutures.  Wound 
healed  well. 


TABLE    V.— OPERATIONS 

PERFORMED    BY 


Yeae. 

No. 

Initials. 

Sex. 

Age. 

Leading  Symptoms. 

1886 

1 

J.  M. 

Female. 

41 

Severe  fall  when  11  years  old, 
and  afterwards  always  had 
occasional  pains  in   right 
side,  which  became  worse 
and    more    continuous     6 
months  before   admission. 
Right  kidney  very  movable 
and   could   be  pushed  in 
any  direction. 

1886 

2 

H.  B. 

Female. 

56 

Sharp  pains  in  abdomen  and 
loins   for  2  years,   getting 
worse.  Right  kidney  freely 
movable. 

1887 

3 

M.  R. 

Female. 

25 

Pain  in  abdomen  with  nausea 
and  vomiting  for  4  months. 
Tender  movable  kidney  on 
right  side. 

1887 

4 

R.  R. 

Female. 

40 

Noticed  swelling  in  right  side 
of  abdomen  15  years.     Re- 
current attacks  of  pain  and 
nausea.    Movable  kidney 
on  right  side. 

1887 

5 

S.  B. 

Female. 

46 

Shooting  pains    in   abdomen 
and  loins  for  three  years. 
Both  kidneys  freely  mov- 
able. 

1887 

6 

S.  B. 

Female. 

46 

See  above,  No.  5. 

1887 

7 

E.N. 

Female. 

36 

Diarrhoea    and    vomiting     6 
weeks    before    admission, 
and     after    that,    noticed 
painful  swelling  on  right 
side  of  abdomen. 

i 

FOR    MOVABLE    KIDNEY. 

MR.    HENRY    MORRIS. 


Date  of  Operation. 


Result. 


Remarks. 


Mar.  30th,  1886,  R.  Kidney. 


Recovered. 


June  30th,  1886,  R.  Kidney. 


Jan.  29th,  1887,  R.  Kidney. 


Apr.  7th,  1887,  R.  Kidney. 


May  10th,  1887,  L.  Kidney. 


Dec.  7th;  1887,  R.  Kidney. 


Oct.  12th,  1887,  R.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Thick  catgut  passed  through 
capsule  and  cortical  part  of 
renal  substance.  Discharged 
well,  and  kidney  was  felt  in 
position  some  months  after- 
wards.    No  sinus. 


Discharged  well.    Sutures  into 
renal  substance. 


Three  sutures  passed  through 
substance  of  right  kidney, 
fixing  it  to  parietes  pos- 
teriorly.    Discharged  well. 

Discharged  well.  Own  method. 
3  sutures  in  renal  substance. 


Two  silk  sutures  in  fibro-fatty 
capsule,  and  two  catgut  su- 
tures into  renal  substance 
used.     Discharged  well. 

(For  second  operation  on  the 
other  kidney,  v.  No.  6.) 

Two  small  silk  sutures  in  cap- 
sule and  three  kangaroo-ten- 
don sutures  through  renal 
substance.     Discharged  well. 

(For  first  operation,  v.  No.  5.) 


Six  sutures  used, 
well. 


Discharged 


212       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Yeak. 


1889 


1889 


1889 


1890 


1890 


1891 


1891 


No. 


10 


11 


12 


13 


14 


Initials. 


H.  F. 


L.  H. 


Mrs.  C. 
(p) 


E  H. 


J.  W. 


Mrs.  I. 

(p) 


Miss  S. 
(p) 


Sex. 


Female. 


Female. 


Female. 


Female. 


Female. 


Female. 


Female. 


Age. 


30 


38 


36 


49 


32 


34 


25 


Leading  Symptoms. 


Attacks  of  pain  —  worse  on 
movement — in  right  loin 
for  seven  years.  Right  kid- 
ney movable. 

Fifteen  months  ago  fall  from 
a  chair.  Eight  months  ago 
premature  confinement. 
Abdominal  pain  and  nau- 
sea for  5  months.  Right 
kidney  movable  and  ten 
der. 

Acute  attacks  of  right  renal 
colic,  often  necessitating 
prolonged  administration 
of  chloroform. 


Pain  in  loins  for  3  months, 
and  noticed  a  freely  mov- 
able lump  in  the  right  side. 
A  hard,  smooth,  elastic 
tumour  felt,  freely  mov- 
able, and  descending  with 
respiration. 

Swelling  felt  in  abdomen  for 
2  years.  Aching  pain  for 
6  months.  A  smooth,  hard, 
elastic  swelling  moving  on 
respiration  was  found  in 
right  lumbar  region. 

Pain  on  right  side  very-severe 
at  times. 


Pain  and  sense  of  dragging. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       213 


Date  of  Operation'. 


Mar.  1st,  1889,  R.  Kidney. 


June  8th,  1889,  R.  Kidney. 
Aug.   8th,   1889,  Removal 

of  uterine  appendages, 

and  uterus  fixed. 


Jan.  17th,  1889,  R,  Kidney. 


Result. 


Nov.  19th,  1890,  R.  Kidney 


Dec.  10th,  1890,  R.  Kidney. 


Apr.  5th,  1891,  R.  Kidney. 


Apr.  6th,  1891,  R,  Kidney. 


Recovered. 


Recovered 

from 

operation,  but 

not  improved. 


Recovered. 


Remarks. 


Recovered. 


Recovered 


Recovered. 


Recovered. 


Three  kangaroo-tendon  sutures 
passed  through  the  renal 
cortex.    Discharged  well. 


Sutures  in  renal  substance. 
No  relief.  After  second 
operation,  was  known  to  be 
well  many  months  later. 

(V.  Med.  Hosp.  Report,  1890, 
p.  149.) 


Two  kangnroo  -  tendon  sutures 
passed  through  the  substance 
of  the  kidney  and  into  the 
muscles.  Two  silk  sutures 
passed  into  areolar  tissue 
capsule  in  front,  and  one 
behind,  and  brought  forward 
to  the  skin.  A  short  sinus 
in  the  centre  of  the  scar  per- 
sisted for  a  short  time,  but 
finally  healed. 

Four  kangaroo-tendon  sutures 
passed  through  the  capsule 
and  renal  substance.  Dis- 
charged well. 


Three  kangaroo-tendon  sutures 
were  passed  through  the  cap- 
sule into  the  renal  substance, 
and  then  through  the  mus- 
cular walls  of  the  parietes. 


The  kidney  was  fixed  by  1 
kangaroo  tendon  and  2  stout 
catgut  sutures.  The  kan- 
garoo tendon  was  passed 
deeply  into  structure  of  the 
kidney.  Was  seen  Dec.  14th, 
1892,  and  was  quite  well. 

The  kidney  was  fixed  (author's 
method),  and  patient  was 
seen  to  be  quite  well  a  year 
afterwards.  Quite  well  ever 
since. 


214       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Yeah. 

No. 

Initials. 

Sex. 

Age. 

Leading  Symptoms. 

1892 

15 

Miss  B. 
(P) 

Female. 

30 

Three  severe  attacks  of  right 
renal  colic  within  8  months. 
Eight  kidney  very  mobile. 
Can  be    pushed    over    to 
middle     line,     downwards 
into  iliac   fossa,   and   up- 
wards under  liver. 

1892 

16 

L.W. 

(p) 

Male. 

27 

Symptom    resembling    renal 
calculus.     Previous  opera- 
tion for  another  affection, 
not  renal,  on  Sep.  20th,l  892, 
and  for   which  he   rested 
completely  until  Oct.  3rd, 
but    with    no    relief ;    so 
movable  kidney  was  fixed. 

1892 

17 

Miss  R. 
(P) 

Female. 

48 

Occasional  attacks  of  pain  in 
right  renal   region  for  10 
years.     The  attacks  have 
been  getting  more  frequent. 
Right  kidney  is  movable. 

1892 

18 

M.M. 

Female. 

43 

Intermittent    pain    in    back, 
and    especially  the    right 
loin,  for  five  years. 

1893 

19 

E.G. 

Female. 

41 

Sharp    pains  in  left  lumbar 
region,    with    attacks    of 
vomiting.      Right  kidney 
found  to  be  freely  mov- 
able. 

1893 

20 

L.  B. 

Female. 

47 

minal  w 
afterwa 
accompj 
tliekidn 

Bight  kidney  had  been  pre- 
viously sutured  to  abdo- 
all  by  another  surgeon.   A  year 
rds  it  again  became  movable,  and 
mied  by  pain, and  on  examination 
eywasfoundtobe  freely  movable. 

TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       215 


Kesult. 


Remarks. 


Oct.  1st,  1892,  R.  Kidney. 


Recovered. 


Nov.  23rd,  1892,  L.  Kidney. 


Recovered. 


June  16th,  1892,  R.  Kidney. 


Recovered. 


Dec.  22nd,  1892,  L.  Kidney. 


Recovered. 


May  30th,  1893,  R.  Kidney. 


Recovered. 


Dec.  5th,  1893,  R,  Kidney. 


Recovered. 


The  kidney  was  fixed  (author's 
method),  and  the  patient 
made  a  good  recovery. 


Nephropexy  by  author's  method. 
Wound  healed  well.  Patient 
seen  in  1893  and  was  well. 


The  kidney  was  excessively 
movable  and  placed  so  low 
down  that  its  upper  end  first 
presented  itself  at  the  lumbar 
incision.  Three  kangaroo- 
tendon  sutures  were  used  to 
fix  the  organ  to  the  loin. 
A  shallow  sinus  remained 
which  subsequently  closed. 
In  excellent  health  ever  since. 

The  kidney  was  slightly  enlarged. 
An  incision  was  made  into 
convex  border,  but  nothing 
abnormal  found.  The  kidney 
was  fixed  to  the  surrounding 
structures  by  a  kangaroo 
tendon  passed  through  its 
posterior  surface,  and  the 
capsule  was  also  fixed. 

The  kidney  was  fixed  by  thick 
catgut  suture  passed  into  it 
and  also  through  the  capsule 
and  the  abdominal  wall.  A 
piece  of  the  renal  capsule 
was  brought  up  through  the 
wound  and  cut  off.  Wound 
healed  well. 

The  kidney  was  fixed  to  the 
abdominal  wall  by  three 
kangaroo  -  tendon  sutures 
passed  into  renal  substance. 
Wound  healed  well. 

(See  Table  IV.,  No.  25.) 


216       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    Y. 


Year. 


1893 


1893 


No. 


21 


22 


Initials. 


Sex. 


1894 


1894 


1894 


1894 


23 


24 


Mrs.  S. 
(?) 


Mrs.  L. 
(P) 


Mrs.  S. 
(p) 


25 


26 


Mrs.  H. 
(p) 


Mrs.  S. 
(?) 


Mr.  B. 

(p) 


Female. 


Female. 


Female. 


Age. 


Female. 


Female. 


Male. 


23 


63 


32 


30 


20 


Leading  Symptoms. 


Pain  in  right  kidney,  fre- 
quency of  micturition,  con- 
stipation, nausea.  Parox- 
ysmal seizures.  Worse 
since  marriage. 

Pain  in  right  side.  Dyspep- 
tic troubles,  nausea  and 
constipation. 


Aching  pain  in  right  renal  re- 
'  gion  for  17  months.  Right 
kidney  normal  and  smooth, 
moves  like  a  ball,  and 
descends  Avhen  patient 
rises  from  recumbent  to 
sitting  posture. 

Paroxysmal  attacks  of  pain 
on  right  side,  resembling 
renal  colic.  Pain  and 
tenderness  on  manipula- 
tion, but  no  movement  of 
kidney  made  out. 


Micturition  very  frequent. 
Eight  kidney  very  mobile 
and  complicated  by  an 
abdominal  swelling,  which 
proved  to  be  distended 
gall-bladder. 


During  one  year  occasional 
severe  attacks  of  colic,  ac- 
companied by  hsematuria. 
Passed  a  stone  in  Novem- 
ber, 1893,  and  2  fragments 
since ;  but  still  had  pain 
in  right  renal  region. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       217 


Date  of  Opekation. 


February  14th,  1893. 


April  13th,  1893. 


Feb.  4th,  1894,  R.  Kidney. 


Feb.  16th,  1894,  R.  Kidney. 


Feb.  23rd,  1894. 
Nephropexy     by     Hahn's 
method.         Cholecyst- 
otomy. 


July  5th,  1894,  E.  Kidney. 


Result. 


Recovered. 


Recovered. 


Recovered. 


Recovered 


Recovered. 


Recovered. 


Remakes. 


Wound  healed  well.  Complete 
relief  of  symptoms.  Author's 
method.  Three  sutures 
through  substance  of  kidney. 


Author's  method.  Complete  re- 
covery from  operation  in  spite 
of  severe  attacks  of  acute  bron- 
chitis. Died  some  months 
subsequently  of  hemiplegia. 

Kidney  was  fixed  by  author's 
method,  and  patient  made  a 
rapid  and  complete  recovery. 


Kidney  freely  movable  upwards, 
downwards,  and  towards  the 
median  line.  Kidney  incised 
and  found  to  be  in  an  early 
stage  of  hydronephrosis.  No 
calculus.  Catgut  sutures 
were  passed  into  the  kidney 
substance  (and  the  shortened 
fibro-fatty  capsule).  Healed 
by  first  intention. 

By  lumbar  incision,  stone  felt 
in  cystic  duct.  Langen- 
buck's  incision.  Cholecyst- 
otomy ;  gall  stone  re- 
moved. The  kidney  was 
fixed  to  the  loin  by  its  fibro- 
fatty  capsule  only.  Patient 
made  good  recovery,  and  has 
remained  well  since. 

(V.  Brit.  Med.  Joum.,  1895, 
Vol.  1,  p.  241.) 

The  kidney  was  extremely  mov- 
able, and  fell  over  to  the 
front  of  the  spinal  column. 
It  was  brought  to  the  surface 
of  the  wound  and  incised, 
but  no  stone  was  found. 
Renal  incision  sutured.  The 
kidney  was  fixed  by  3  sutures 
into  renal  substance,  and  the 
wound  healed  well. 


218        OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Yeah. 


1894 


1895 


1895 


1895 


1895 


1895 


No. 

i 
Initials. 

Sex. 

Age. 

27 

E.  E. 

Female. 

27 

28 

Mr.  S. 

(p) 

Male. 

37 

29 

C.  P. 

Female. 

30 

30 

M.  H. 

Female. 

37 

31 

A.  W. 

Male. 

47 

32 

Miss  B. 
(p) 

Female. 

37 

Leading  Symptoms. 


Noticed  a  lump  in  right  side 
for  5  years  ;  also  constant 
attacks  of  aching  pain. 
Eight  kidney  could  be  felt 
to  be  movable. 


Constant  renal  pain  for  6 
years.  Hematuria  after 
exercise  for  several  months. 
Urine  always  contains  ex- 
cess of  phosphates. 


A  dragging  pain,  sometimes 
very  acute,  in  the  right 
loin  for  3  years.  Pain 
worse  after  exercise.  Kid- 
ney freely  movable,  both 
in  downward  and  lateral 
direction. 


Pain  in  back  and  groins  for  9 
months,  and  some  fre- 
quency of  micturition 
and  slight  pyuria.  The 
right  kidney  was  freely 
movable. 


Paroxysmal  pain  in  the  right 
loin.  There  was  tender- 
ness and  fulness  of  the 
right  kidney,  which  was 
distinctly  movable. 


Continual  pain.  Has  laid  up 
twice  for  3  or  4  weeks 
during  last  18  months,  but 
the  pain  always  returns 
again  when  she  gets  up. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY. 


219 


Date  of  Operation. 


Aug.  7th,  1894,  R.  Kidney. 


Aug.  3rd,  1895,  L.  Kidney. 


Apr.  13th,  1895,  E.  Kidney. 


Jan.  29th,  1895,  E.  Kidney. 


Jan.  2nd,  1895,  E,  Kidney. 


July  24th,  1895,  L.  Kidney. 


Result. 


Eecovered. 


Eecovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Remarks* 


The  kidney  was  carefully  ex- 
amined for  stone,  but  none 
found  (it  was  not  incised). 
It  was  firmly  fixed  to  the 
abdominal  wall  by  3  kangaroo- 
tendon  sutures  passed  through 
the  kidney  substance. 


The  kidney  was  brought  on  to 
the  loin  and  thoroughly  ex-, 
amined.  An  incision  was 
made  in  the  convex  border 
and  the  pelvis  explored,  but 
nothing  found,  and  the 
wound  was  sutured.  The 
kidney,  however,  was  freely 
movable,  and  it  was  fixed. 
A  stone  was  passed  many 
months  afterwards. 


Own  method.  Good  recovery. 
Quite  relieved  ;  but  returned 
November  12th,  1895,  com- 
plaining of  some  pain  in  left 
side,  but  no  operation  deemed 
necessary.  Right  kidney 
satisfactorily  fixed. 


The  kidney  appeared  quite 
healthy.  The  kidney  was 
fixed  to  the  abdominal  wall 
by  3  stout  gut  sutures  passed 
through  the  cortex  on  the 
anterior  surface  of  the  kid- 
ney. Uninterrupted  reco- 
very.    Discharged  well. 


The  kidney  appeared  quite 
healthy,  and  was  sutured  to 
the  walls  by  3  strong  gut 
sutures.  Wound  healed  well. 


Kidney  fixed.  Wound  healed 
by  first  intention,  and  patient 
was  seen  to  be  quite  well  in 
August,  1896. 


220        OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Yeae. 


No. 

Initials. 

Sex. 

Age. 

33 

W.  M. 

Male. 

40 

34 

F.  B. 

Male. 

22 

35 

Miss  M. 
(p) 

Female. 

39 

36 

Mrs.H. 
(p) 

Female. 

23 

37 

Miss  J. 
(p) 

Female. 

24 

Leading  Symptoms. 


1895 


1895 


1895 


1895 


1895 


Attacks  of  pain  in  left  side 
and  vomiting  for  4  years. 
Occasional'  hematuria. 


Paroxysmal  pain  in  right  side, 
shooting  into  right  testis, 
with  severe  hematuria 
since  April,  1895.  Mictu- 
rition increased  in  fre- 
quency and  urine  in  quan- 
tity. 

First  seen  in  1890.  Previously 
had  suffered  from  ovaritis. 
Intense  pain,  sickness, 
dragging  feeling,  and 
constipation.  Dyspeptic 
troubles.  Worse  at  mens- 
trual periods,  when  kidney 
would  greatly  swell  in  size. 

Both  kidneys  were  movable 
and  the  left  greatly  in- 
creased at  intervals.  Diag- 
nosed by  me  as  inter- 
mittent hydronephrosis. 


In  1891  strain  from  lifting, 
when  she  felt  something 
"  go."  Since  then  attacks 
of  sharp  stabbing  pain  in 
right  side,  shooting  along 
in  direction  of  ureter. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       221 


Date  of  Operation. 


Result. 


Remarks. 


Nov.  16th,  1895,  L.  Kidney. 


Recovered. 


Nov.  30th,  1895,  R.  Kidney. 


Oct.  30th,  1895. 


Oct.  28th,  1895,  L.  Kidney. 


July  11th,  1895,  R.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


The  kidney  appeared  puckered 
on  the  surface  and  the  peri- 
renal tissue  was  very  dense 
and  adherent.  An  incision 
was  made  into  the  convex 
border  and  the  kidney  was 
explored,  but  nothing  was 
found.  The  renal  incision 
was  sutured,  and  the  kidney, 
which  was  movable,  was 
fixed.  The  wound  healed 
well,  and  patient  wrote  after- 
wards, saying  he  was  much 
better  since  the  operation. 
Has  reported  himself  every 
6  months  since,  and  keeps 
in  perfect  health. 

An  incision  was  made  into  con- 
vex border  of  kidney  and 
the  finger  introduced,  but  no 
stone  found.  The  kidney, 
which  was  freely  movable, 
was  fixed  by  sutures  through 
capsule  and  cortex. 

Own  method.  Good  recovery. 
Right-sided  pain  and  drag- 
ging quite  relieved,  but  pain 
in  hypogastrium,  subse- 
quently felt  at  monthly 
periods.  Suffering  at  pe- 
riods and  profuse  floodings 
keep  her  in  poor  health. 

The  left  kidney  was  found  to 
be  shrunken  and  hydrone- 
phrotic,  with  dilated  pelvis, 
and  it  was  fixed  to  the  loin. 
Good  recovery  from  opera- 
tion, but  subsequent  inter- 
mittent attacks,  and  removal 
advised.  Nephrectomy  was 
subsequently  performed  in 
this  case  by  another  surgeon 
in  September,  1896. 


Kidney  had  been  fixed  on  April  12, 1S95,  by 
another  surgeon.  Subsequent  attacks 
of  intermittent  hydronephrosis.  July 
11th  the  kidney  was  found  fixed,  but  in  nearly  transverse  posi- 
tion. It  was  detached  and  refixed  in  normal  position.  Quite 
well  and  without  pain  when  last  seen  in  September,  1S95  ;  but 
it  was  a  question  if  hydronephosis  might  not  recur.  Not  heard 
of  since. 


222       OPERATIONS    FOB   MOVABLE    KIDNEY.— TABLE    V. 


Yeab. 


No. 


1895 


1895 


1896 


1896 


38 


39 


40 


41 


Initials. 


Mrs.  P. 
(P) 


Miss  P. 
(p) 


Miss  P. 
(p) 


Mrs.  D. 
(?) 


Sex. 


Female. 


Female. 


Female. 


Female. 


Age. 


Leading  Symptoms. 


43 


42 


35 


40 


Pain  in  right  renal  region, 
especially  after  any  exer- 
tion. Some  pyuria.  The 
right  kidney  was  felt  to 
be  movable. 


Pain  for  a  long  time  in  right 
side  of  abdomen,  which  is 
made  worse  by  exercise 
and  always  ceases  during 
rest.  Right  kidney  very 
freely  movable  in  all 
directions. 

Pain  in  left  side  and  sickness 
for  6  years.  Pain  is  fol- 
lowed by  passage  of  large 
amount  of  urine.  The  left 
kidney  was  very  mobile, 
and  occupied  an  obliquely 
transverse  position.  The 
right  kidney  was  also  very 
movable,  but  not  the  seat 
of  much  pain. 


Intensely  neurotic.  Dyspeptic^ 
symptoms,  constipation, 
dragging  pain  in  right 
side.  Eight  kidney  very 
movable. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       223 


Date  of  Operation. 


Result. 


Remarks. 


March  27th,  1895,  both 
kidneys  explored  by- 
abdominal  incision 
through  right  semi- 
lunaris, and  then  the 
right  was  explored 
and  fixed  through  a 
lumbar  incision. 


Recovered. 


Jan.  30th,  1895,  R.  Kidney. 


Recovered. 


May  5th,  1896,  R.  Kidney 


Recovered. 


April  19th,  1896,  R.  Kidney. 


Recovered. 


By  the  abdominal  incision  the 
left  kidney  was  felt  to  be 
normal  in  size  and  position, 
while  the  right  was  freely 
movable  in  any  direction. 
The  abdominal  wound  was 
closed,  and  the  right  kidney 
was  exposed  by  a  lumbar  in- 
cision, explored  through  in- 
cision in  convex  border,  and 
fixed  by  3  sutures.  Wound 
healed  well.  9th  June,  1896  : 
"  doing  wonders  in  walking, 
and  feeling  quite  well."  In 
December,  1897,  heard  she 
was  suffering  in  same  side, 
after  a  fall  over  piece  of  fur- 
niture, and  now  has  relapses 
of  pain. 

The  kidney  was  fixed  with  3  silk 
sutures.  Wound  healed 
rapidly,  but  later  on  broke 
down  at  one  spot,  and  2  silk 
sutures  came  away.  Has 
been  greatly  benefited  by 
operation.     Sinus  healed. 

The  right  kidney  was  exposed, 
brought  on  to  the  loin,  and 
carefully  examined,  but  not 
incised.  Three  sutures  were 
passed  into  post,  surface  of 
the  organ  and  returned 
through  fascia  and  muscles. 
Wound  healed  by  first  in- 
tention. The  left  kidney  was 
subsequently  also  fixed. 

(F  Table  V.,  No.  43.) 


The  kidney  was  fixed  and 
patient  much  improved,  and 
the  wound  healed  ;  but  sub- 
sequently a  shallow  fistula 
formed.  Became  pregnant 
in  June,  1896,  and  between 
2  and  3  months  after  labour,  symptoms  of 
general  septicaemia  occurred.  This  was  in  June, 
1897.  Nephrectomy  was  performed  after  a  few 
days  of  marked  typhoid  symptoms.  Kidney 
found  well  fixed,  but  softened,  and  in  condition 
of  ascending  suppurative  pyelonephritis, 
(See  Table  VIII.,  No.  5.) 


224       OPERATIONS    FOE,    MOVABLE    KIDNEY.— TABLE    V. 


Year.  No.        Initials.       Sex.  Age 


1896 


1896 


1896 


1896 


42 


43 


44 


45 


L.H. 
(p) 


Miss  P. 
(?) 


Mr.  S. 
(p) 


Miss  H. 
(p) 


Female. 


Female. 


Male. 


Female. 


53 


35 


43 


38 


Leading  Symitoms. 


In  September,  1895,  had  severe 
pain  in  right  renal  region, 
attended  with  hematuria, 
and  a  very  severe  repetition 
occurred  in  1896,  with  a 
great  deal  of  hsematuria. 
The  right  kidney  was  felt 
to  be  enlarged,  and  very 
movable  and  very  tender. 


For  symptoms  and  previous 
operation  on  right  kidney, 
y.  Table  V.,  No.  40. 

Pain  in  left  kidney,  but  has 
never  I  been  so  severe 
since  its  twisted  position 
was  rectified  by  manipu- 
lation shortly  before 
operation  on  the  right 
kidney. 

Occasional  attacks  of  pain 
and  hsematuria  since  Oct., 
1895 — worse  after  exercise. 
Eight  kidney  movable. 


Pain  in  right  side  and  movable 
kidney  for  2  years. 


TABLE    V.— OPERATIONS   FOB    MOVABLE    KIDNEY.       225 


Date  of  Operation. 


March.  25th,  1896,  R. 
Kidney. 


July  15th,  1896,  L.  Kidney. 


Result. 


Recovered. 


Recovered. 


Remarks. 


Jan.  22nd,  1896,  R.  Kidney. 


Dec.  6th,  1896,  R.  Kidney. 


Recovered. 


Recovered. 


The  kidney  was  very  large,  and 
on  incising  it,  it  was  found 
that  the  pelvis  and  calyces 
were  distended  with  blood - 
clot,  some  of  which  were 
blackish  -  grey  in  colour. 
Intra-renal  haemorrhage.  No 
calculus  was  found,  and  ureter 
was  normal.  The  wound  in 
the  kidney  was  closed  by  fine 
sutures  and  the  kidney  fixed 
in  position.  After  the  opera- 
tion the  pain  was  entirely 
relieved,  and  the  kidney 
rapidly  subsided,  but  haema- 
turia  continued  for  weeks. 
The  patient  subsequently 
recovered,  and  is  now 
well. 

The  kidney  was  flaccid  and 
hydronephrotic.  It  was  fixed 
in  a  similar  manner  to  the 
right.  A  purulent  fistula  re- 
mained for  a  time,  and  pus 
was  passed  in  urine,  but 
finally  closed. 

(For  previous  operation,  v. 
Table  V.,  No.  40.) 


Kidney  exposed,  brought  to  sur- 
face of  wound,  and  incised 
along  convex  border.  No 
stone  found.  The  renal 
wound  was  sutured,  and  the 
kidney  was  fixed  by  two  silk 
sutures  passing  into  kidney 
and  returned  through  muscles 
and  fascia  of  loin.  Fistula 
remained  for  several  months, 
due  to  sutures  escaping,  and 
then  finally  closed.  A  small 
oxalate  and  phosphate  of  lime 
calculus  was  passed  on  Feb. 
9th,  1897. 

The  kidney  was  fixed  with  3 
sutures.  The  wound  healed 
by  first  intention.  A  fistula 
formed  later,  and  kept  open 
till  2  sutures  escaped,  and 
then  healed  permanently. 


226       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Year. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1896 


46 


E.  S. 


Female. 


1896 


47 


Miss  E. 
(p) 


Female. 


1897 


48 


Miss  P. 
(?) 


Female. 


1897 


49 


Mrs.  A. 
(?) 


Female. 


1897 


50 


L.  W. 
(p) 


Male. 


54  Pain  and  tenderness  in  right 
loin.  Abdominal  walls 
very  lax.  On  standing, 
right  kidney  slips  alto- 
gether below  the  umbili- 
cus. 

56  Very  movable  kidney.  Parox- 
ysmal pain  (with  vomiting) 
in  right  side.  Sense  of 
pressure  and  dragging  in 
right  side.  Attacks  last 
for  2  or  3  days,  during 
which  she  is  very  prostrate, 
and  looks  sallow,  pinched, 
and  very  ill.  Symptoms 
several  years. 

Previously  had  uterine  ap- 
pendages removed  for 
tuberculous  disease.  Pus 
was  passed  by  the  rectum, 
and  had  also  once  an  attack 
of  hematuria.  There  was 
some  doubt  as  to  enlarge- 
ment of  right  kidney,  as 
it  was  obscured  by  the 
liver,  which  was  lower  than 
normal. 


Eight  hip-joint  ankylosecl 
since  childhood.  Frequent 
attacks  of  pain  with  fre- 
quency of  micturition  for 
a  year.  Left  kidney  very 
movable.  A  little  pus 
and  several  crystals  of 
calcium  oxalate  in  urine. 


49  Very  neurotic,  but  led  an 
active  life  in  Army  Indian 
service.  Since  1895  at- 
tacks of  acute  pain  in  left 
renal  region.  Porter-like 
urine  during  attacks.  Hematuria, 
with  pain,  especially  after  walking, 
since  July,  1896.  There  is  now  a 
heavy  aching  pain  in  line  of  ureter. 
Some  stenosis  of  sigmoid  flexure. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       22/ 


Date  of  Operation. 


May  25th,  1896,  R.  Kidney. 


Feb.  12th,  1896,  R.  Kidney. 


June  2nd,  1897,  R.  Kidney. 
Exploratory  laparo- 
tomy. Firm  adhesions 
found  shutting  off  the 
kidney,  so  an  incision 
in  the  loin  was  made. 


Feb.  19th,  1897,  L.  Kidney. 


Result. 


Dec.  16th,  1897,  L.  Kidney. 


Recovered. 


Recovered. 


Recovered 

from 
operation. 
Symptoms 
relieved, 
but  patient 
still  feeble. 


Recovered. 


Remarks. 


Recovered. 


Kidney  fixed  by  3  sutures  passed 
deeply  through  the  kidney 
tissue.  March,  1898— says 
she  has  been  better  since  the 
operation  than  for  many 
years  past. 

Author's  method.  Rapid  heal- 
ing. Complete  recovery  from 
former  symptoms.  Seen  from 
time  to  time.  Is  quite  free 
of  old  symptoms  at  the  pre- 
sent time. 


The  kidney  was  found  to  be  over- 
lapped by  the  right  lobe  of 
the  liver,  but  normal,  though 
freely  mobile.  The  kidney 
was  thoroughly  examined, 
but  not  incised.  There  were 
marked  adhesions  between 
the  intestine  and  kidney. 
Some  of  the  fibro-fatty  cap- 
sule was  cut  away,  and  one 
suture  was  passed  through  the 
kidney.    Wound  healed  well. 

Kidney  found  to  be  excessively 
movable,  having  a  complete 
mesonephron.  Incised  and 
examined,  but  no  stone  or 
tubercle  found.  The  incision 
was  sutured  and  the  kidney 
was  fixed  by  3  sutures.  A 
purulent  fistula  existed  for 
some  time,  and  has  not  yet 
quite  healed. 


Kidney  incised  along  convex 
border.  Explored.  Sutured 
with  3  sutures.  Ureter  catheterised,  but  not 
found  to  be  satisfactorily  free.  The  slight  ob- 
struction was  thought  to  be  due  to  kinking.  No 
stone.  Fixed  by  author's  method.  Complete  and 
rapid  healing.  Some  pain,  with  constipation, 
since.  No  trace  of  old  pain  and  attacks  so 
far. 

(Postscript. — He  passedj.a  small  ovoid  calculus 
on  May  28th,  1898.) 


228       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Year. 


1897 


1897 


1897 


1897 


No. 


51 


52 


53 


54 


Initials. 


Miss  M. 
(p) 


P.  C. 


B.C. 


E.  A. 


Sex. 


Female. 


Female. 


Male. 


Female. 


Age. 


41 


37 


26 


29 


Leading  Symptoms. 


For  11  years  pain  in  right 
renal  region.  Never  hserna- 
turia.  Of  late  perpetual 
aching,  and  every  6  months 
(about)  very  severe  parox- 
ysmal attacks.  Is  now 
unable  to  follow  calling  as 
teacher  of  music. 


Sharp  attacks  of  pain  in  the 
right  side.  Frequency  of 
micturition.  The  right 
kidney  moves  with  respira- 
tion, and  can  easily  be 
moved  by  pressure  with 
the  hand. 


Pain  in  left  side  for  2  years, 
and  almost  constant  for 
the  last  year. 


In  Oct.,  1896,  patient  strained 
herself  by  lifting  a  weight. 
After  that  occasional  pain 
in  loins  and  hsematuria. 
Urine  contained  some  pus, 
blood,  and  albumen. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       229 


Date  of  Operation. 


Result. 


Remarks. 


Dec.  6th,  1897,  R.  Kidney.       Recovered 


June  1 4th,  1897,  R.  Kidney. 


June  21st,  1897,  L.  Kidney. 


Dec.  17th,  1897,  R.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


The  kidney  was  fixed  by  means 
of  a  tendon  of  the  longissimus 
dorsi.  Vulliet's  method 
modified.  Recovery  without 
a  fistula. 


Kidney  fixed  by  a  modification 
of  Vulliet's  method.  Wound 
healed  well,  and  patient  dis- 
charged free  from  pain. 


The  kidney  was  found  to  be 
very  movable,  and  an  incision 
was  made  into  its  substance, 
but  nothing  felt.  The  kidney 
was  firmly  fixed  to  the  deeper 
layers  of  the  parietal  wall 
by  several  sutures  passed 
through  a  detached  portion  of 
the  fibrous  capsule.  Tufner's 
method.    Wound  healed. 


The  kidney  was  found  to  be 
freely  movable  and  rather 
small.  The  cortex  was  in- 
cised and  the  kidney  ex- 
plored. A  small  incision 
was  also  made  in  the  renal 
pelvis,  and  the  ureter 
catheterised ;  found  to  be 
quite  free  from  obstruction. 
Wound  in  pelvis  closed  by 
one  suture,  and  that  of  renal 
cortex  by  four.  The  kidney 
had  the  appearance  of 
chronic  tubular  nephritis. 
The  kidney  was  fixed  by 
two  sutures  passed  through 
its  capsule  and  the  edges  of 
the  deep  tissues  of  parietal 
incision.  Wound  healed 
well,  patient  feels  well,  but 
urine  still  contained  some 
blood  and  albumen. 


230       OPERATIONS    FOB    MOVABLE    KIDNEY.— TABLE    V. 


Yeae. 


1898 


1898 


1898 


No. 


55 


56 


57 


Initials. 


E.  W. 


M.  I. 


E.E. 


Sex. 


Female. 


Female. 


Female. 


Age. 


28 


Leading  Symptoms. 


29 


40 


Pain  in  back  for  2  years,  sud- 
denly got  much  worse  in 
Nov.,  1897.  Left  kidney 
freely  movable  in  almost 
any  direction,  and  the  right 
kidney  was  also  slightly 
movable. 

Dragging  pain  in  right  loin 
for  3  years.  Worse  on 
exertion.  The  right  kid- 
ney was  slightly  enlarged 
and  freely  movable. 

Intermittent  pain  in  right 
loin  in  Nov.,  1897 ;  and 
soon  afterwards  a  swelling 
was  noticed.  The  attacks 
of  pain  were  worse  after 
exertion.  Urine  was  often 
dark  in  colour.  The  right 
kidney  was  found  to  be 
freely  movable. 


TABLE    V.— OPERATIONS    FOB    MOVABLE    KIDNEY.       231 


Date  op  Operation. 


Feb.  14th,  1898,  L.  Kidney. 


Feb.  3rd,  1898. 


Feb.  28th,  1898. 


Result. 


Recovered. 


Recovered. 


Recovering. 


Remarks. 


The  kidney  was  fixed  by  a  mo- 
dification of  Vulliet's  method. 
Wound  healed  well. 


The  kidney  was  fixed  by  a 
modification  of  Vulliet's 
method.  Wound  healed  well. 


The  kidney  was  exposed  by  an 
incision  through  the  loin,  and 
when  examined  with  the 
fingers  a  peculiar  crackling 
occurred  like  that  produced 
by  surgical  emphysema.  On 
opening  the  capsule  a  large 
subcapsular  haemorrhage  was 
found,  and  the  capsule  had 
been  completely  detached 
from  the  parenchyma.  An 
incision  was  made  into  the 
convex  border  of  the  kidney 
and  the  organ  explored, 
but  nothing  further  was 
found.  The  cut  edges  of 
the  renal  capsule  were  sewn 
to  the  edges  of  the  incision, 
leaving  a  part  of  the  kidney 
uncovered  by  capsule,  in 
contact  with  the  abdominal 
wall. 


TABLE   VI.— HYDRONEPHROSIS 

PERFORMED    BY 


Year. 

No. 

Initial. 

Sex. 

Age. 

Leading  Symptoms. 

1883 

1 

Mr.  J. 

Male. 

22 

Acute  symptoms  of  renal  colic. 
Enormous  tumour  in  left 
loin. 

1885 

2 

G.  D. 

Male. 

43 

Pain  in  loins  and  frequency  of 
micturition.      Stricture  of 
urethra  for  12  years.    Ful- 
ness over  region  of  right 
kidney.     Urine  contained 
pus  and  blood. 

1888 

3 

G.  C. 

Male. 

34 

Duration  of  symptoms  2  years. 
Attacks    of   pain    in    left 
loin.      Pyuria   and    occa- 
sional haematuria. 

1888 

4 

Mrs.  C. 

Female. 

24 

Swelling    in   right   loin   first 
seen  in  May,  1888,  after  an 
injury.     Urine  normal. 

,  1889 

5 

Miss  S. 

Female. 

37 

Renal  swelling  in  left  loin  for 
15  months,  which  had  been 
aspirated. 

1889 

6 

E.  F. 

Female. 

51 

Pain  in  right  loin  for  6  years  ; 
much  worse  during  last  6 
months.  Frequency  of  mic- 
turition, albuminuria,  and 
pyuria.     Indistinct   swell- 
ing in  the  right  loin. 

AND    PYONEPHROSIS. 

MR.    HENRY   MORRIS. 


Nature  and 
Date  of  Operation. 


Result. 


Remarks. 


Nephrotomy. 

Dec.  22nd,  1883. 

L.  Kidney. 


Nephrotomy. 

July  23rd,  1885. 

R.  Kidney. 


Nephrotomy. 

Oct.  26th,  1888. 

L.  Kidney. 


Nephrectomy. 

Dec.  30th,  1888. 

R.  Kidney. 


Nephrectomy. 

Jan.  4th,  1889. 

L.  Kidney. 


Nephrectomy. 

March  1st,  1889. 

R.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Died  Mar.  5th. 


large  hydronephrotic  kidney 
'  was  found  and  very  large 
quantity  of  brown  inodorous 
fluid  withdrawn,  and  also 
some  dark  -  brown  blood- 
clot.  Cyst  wall  was  sutured 
to  skin.  Urinary  fistula  re- 
mained. Patient  seen  in  per- 
fect health  14  years  later. 


A  large  quantity  of  purulent 
urine  escaped  when  the  kid- 
ney was  incised.  The  edges 
of  the  cyst  were  stitched  to 
the  abdominal  wound  and 
drained. 


The  kidney  was  enlarged,  and 
at  one  part  contained  a 
quantity  of  pus,  which  was 
evacuated,  and  the  kidney 
drained. 


Kidney  very  hydronephrotic. 
About  45  oz.  of  clear  fluid 
withdrawn  before  the  organ 
was  removed. 


The  kidney  was  in  an  advanced 
state  of  hydronephrosis,  pro- 
bably the  result  of  a  pre- 
vious pelvic  cellulitis. 

(Subsequent  nephrotomy  on  the 
right  kidney,  v.  Table  VI. , 
No.  9.) 


Kidney  in  an  advanced  state  of 
suppuration.  P.M.  The  other 
kidney  was  hydronephrotic. 
The  disease  was  secondary  to 
pelvic  cellulitis  and  com- 
pression of  the  ureters. 


234    HYDRONEPHROSIS    AND    PYONEPHROSIS.— TABLE    VI. 


Year.  No.       Initials.       Sex.  Age 


Leading  Symptoms. 


1893 


H.  N. 


Male. 


1893 


Mrs.  E. 


Female. 


56 


1893 


Miss  S. 


Female. 


41 


1893 


10 


MissW. 


Female. 


29 


1893 


11 


MissW. 


Female. 


29 


Pain  in  right  loin  for  1  year. 
Hematuria,  pyuria,  and 
albuminuria. 


Duration  of  symptoms,  2  years. 
Pain  in  right  loin  and 
frequency  of  micturition. 
Very  offensive  pus  in  urine. 


Previous  nephrectomy  for 
hydronephrosis  in  January, 
1889.  Tumour  in  right 
hypochondriac  region  the 
size  of  a  child's  head 
and  very  movable. 


Had  suffered  for  some  years 
from  attacks  of  pain  in 
right  lumbar  region,  asso- 
ciated with  a  swelling 
which  was  taken  to  be  a 
floating  kidney.  In  June, 
1893,  the  pain  became 
worse,  and  was  accom- 
panied by  fever  andrigerar 


Nephrectomy  on  account  of 
reappearance  of  a  hydro- 
nephrotic  tumour  after 
nephrotomy. 

(V.  No.  10.) 


TABLE    VI.— HYDRONEPHROSIS    AND    PYONEPHROSIS.     235 


Nature  and 
Date  of  Operation. 


Result. 


Remarks. 


Nephrectomy. 

Jan.  10th,  1893. 

R.  Kidney. 


Nephrectomy. 

Jan.  29th,  1893. 

R.  Kidney. 


Recovered. 


Died  Feb.  3rd. 


Nephrotomy  and  fixation 

of  R.  Kidney. 

Feb.  11th,  1893. 


Recovered. 


Nephrotomy. 

July  20th,  1893. 

R.  Kidney. 


Recovered. 


Nephrectomy. 

July  28,  1893. 

R.  Kidney. 


Recovered. 


Kidney  in  advanced  state  of 
hydronephrosis.  The  upper 
end  of  the  ureter  was 
thickened.  Recovery  with- 
out a  sinus. 

(V.  Lancet,  Vol.  1,  1894.) 

Kidney  a  fibrous  sac  with  lining 
membrane  roughened  by  pa- 
pillary elevations.  Sac  filled 
with  very  offensive  material 
like  semi-fluid  pus  streaked 
with  some  inspissated  mate- 
rial the  colour  of  damson  juice. 
Died  of  uramiia.     No  P.M. 

The  kidney,  which  was  hydro- 
nephrotic,  was  fixed  to  the 
loin  and  drained.  The 
quantity  of  urine  which 
escaped  by  the  fistula 
gradually  decreased,  and 
the  flow  soon  became  well 
established  by  the  natural 
passages.  Nearly  3  pints  of 
healthy  urine  were  passed 
daily,  and  the  kidney  con- 
tracted to  the  size  of  a 
clenched  fist,  and  the  patient 
was  better  than  she  had  been 
for  years. 

Kidney  formed  a  large  lobulated 
cyst,  and  when  incised  was 
found  to  contain  f  pint  of 
straw-coloured  fluid.  There 
was  a  considerable  amount 
of  secreting  substance  left, 
so  the  kidney  was  sutured 
and  the  wound  closed.  The 
patient  was  much  relieved 
tor  a  few  days,  but  the 
tumour  refilled  and  nephrec- 
tomy was  performed. 

(V.  No.  11.) 

The  kidney  was  removed,  the 
wound  healed  well,  and  the 
patient  rapidly  gained  weight 
and  felt  quite  well. 

(For  previous  nephrotomy  and 
the  condition  of  kidney,  v. 
No.  10.) 


236     HYDRONEPHROSIS    AND    PYONEPHROSIS.— TABLE    VI. 


Yeah. 


No. 


1893 


1894 


1895 


1895 


1895 


1897 


12 


13 


14 


15 


16 


17 


Initials. 


M.  K. 


Mrs.  J. 


E.  A. 


M.J. 


E.  S. 


Mrs.  H. 


Sex. 


Male. 


Female. 


Female. 


Female. 


Female. 


Female. 


Age. 


22  hrs. 


27 


28 


35 


21 


57 


Leading  Symptoms. 


Retention    of    urine.      Two 
large  tumours  in  the  loins. 


Movable  right  kidney  for 
several  years,  followed  later 
by  pain  and  enlargement 
of  right  kidney,  with  fre- 
quency of  micturition  and 
pyuria. 

Pain  in  left  side  for  5  years, 
paroxysmal  in  character. 
A  perinephric  abscess  pre- 
viously opened,  which  left 
a  sinus. 


Pain  and  large  tumour  in  left 
loin.    No  pus  in  urine. 


Pain  and  swelling  in  left  loin. 
Pyuria,  albuminuria  and 
slight  hsematuria. 


Symptoms  9  years.  Frequent 
attacks  of  pain  in  left  side. 
No  definite  alteration  in 
urine.  Passed  one  or  two 
concretions  of  doubtful 
character. 


TABLE    VI.— HYDRONEPHROSIS    AND    PYONEPHROSIS.     237 


Nature  and 
Date  of  Opekation. 


Result. 


Remarks. 


Left  ureterotomy. 

Right  nephrotomy. 

Dec.  1st,  1893. 


Nephrotomy. 

Nov.  30th,  1894. 

R.  Kidney. 


Nephrectomy. 

Aug.  28th,  1895. 

L.  Kidney. 


Nephrectomy. 

Oct.  23rd,  1895. 

L.  Kidney. 


Nephrectomy. 

Nov.  22nd,  1895. 

L.  Kidney. 


Nephro-Ureterectomy. 

Oct.  22nd,  1897. 

L.  Kidney. 


Recovered  and 

remained 
well  for  many 
weeks.    Sub- 
sequently 

died  of 
inanition. 


Recovered. 


Died 
Aug.  28th. 


Recovered. 


Recovered. 


Recovered. 


Preliminary  laparotomy,  fol- 
lowed by  nephrotomy  on 
each  side.  The  condition 
was  one  of  double  congenital 
hydronephrosis,  and  a  large 
quantity  of  clear  fluid  was 
obtained  from  each  kidney. 
Death  from  diarrhoea  and  ex- 
haustion on  March  2nd,  1893. 

(Vide  Lancet,  June  8,  1895.) 

Kidney  in  advanced  state  of 
pyonephrosis.  Edges  of  cyst 
wall  were  stitched  to  the 
skin.  Recovery  without  a 
sinus. 


Kidney  contained  large  amount 
of  pus.  Also  there  was  a 
large  amount  in  the  tissues 
round  the  kidney.  Patient 
died  from  collapse  the  same 
day  as  the  operation.  No 
P.M. 

A  preliminary  laparotomy  was 
done  and  the  other  kidney 
felt  to  be  normal.  The 
left  kidney  was  enormously 
enlarged  and  full  of  pus. 
Ureter  very  narrow.  Re- 
covery without  a  sinus. 

Kidney  in  advanced  state  of 
hydronephrosis.  Recovery 
with  only  a  small  superficial 
sinus  when  she  left  hospital, 
and  which  has  almost  cer- 
tainly healed.     Not  heard  of 


Kidney  small  and  very  sac- 
culated. Ureter  excessively 
small  in  diameter,  with  very 
thin  walls.  Plastic  opera- 
tions were  done  upon  this 
ureter,  but  not  giving  pro- 
mise of  satisfactory  results, 
were  abandoned.  A  large 
part  of  the  ureter  was  re- 
moved with  the  kidney. 
Recovered. 


238    HYDRONEPHROSIS    AND    PYONEPHROSIS.— TABLE    VI. 


Year. 


1897 


1898 


1898 


No. 


18 


19 


20 


Initials. 


Mrs.  B. 


Mrs.  M. 


Mr. 
C.  H.  R. 


Sex. 


Female. 


Female. 


Male. 


Age. 


42 


29 


40 


Leading  Symptoms. 


Frequent  and  painful  micturi- 
tion in  1894,  which  was 
thought  to  be  due  to 
cystitis,  and  under  treat- 
ment disappeared  in  a 
year.  Pyuria  since  Oct., 
1896,  but  no  return  of  fre- 
quency of  micturition.  In- 
termittent pain  in  right 
renal  region  for  3  years. 
A  large  tender  swelling 
was  found  to  be  present 
in  the  right  renal  region. 

Aching  in  right  side.  Fre- 
quency of  micturition, 
amounting  almost  to  in- 
continence. Slight  pyuria. 
Had  several  falls  while 
hunting,  and  a  definite 
injury  18  months  ago. 


Hematuria  in  1885,  followed 
by  right  renal  colic — one 
attack  so  severe  that  it 
was  thought  it  would 
prove  fatal.  Interval  of 
freedom  and  fresh  severe 
attacks  in  1894.  Explora- 
tory operation  by  another 
surgeon  in  Nov.,  1895.  No 
stone.  Kidney  found  dis- 
tended and  displaced,  and 
was  fixed.  Symptoms  con- 
tinued unabated  to  present^ 
time,  and  are  now  chiefly 
referred  to  neck  of  bladder. 


TABLE    VI.— HYDRONEPHROSIS    AND    PYONEPHROSIS.     239 


Nature  and  Date  of 

Operation. 

RESULT. 

Remakes. 

Nephrectomy. 

Recovered. 

A  large  sacculated  pyonephrotic 

Feb.,  1897. 

kidney      containing      thick 

K.  Kidney. 

purulent  urine.  In  excellent 
health  at  present  time. 

Ureterotomy  and  nephro- 

Recovered. 

After  exploring  the  bladder  with 

pexy  for   movable  hy- 

negative  result,  an  incision 

dronephrotic  kidney. 

into  right  loin  exposed  the 

Feb.  5th,  1898. 

kidney.     Tough,  fibrous  ad- 

R. Kidney. 

hesions  bound  down  the 
upper  pole  of  the  organ, 
which  was  rotated  through  a 
quarter  of  a  circle,  the  hilum 
looking  upwards.  The  renal 
pelvis  was  considerably  di- 
lated, and  the  ureter  was 
stenosed  at  junction  of  in- 
fundibulum. 

Nephrectomy  and  ^partial 

Recovered. 

Kidney  was  enormously  saccu- 

ureterectomy. 

lated,  only  thin  shell  form- 

March 4th,  1898. 

ing  wall.      The  ureter  was 

R.  Kidney. 

of  immense  thickness, 
and  its  mucous  membrane 
coarsely  granular,  and  grated 
like  a  calculus  on  passing 
a  bougie.  Marked  peri- 
ureteritis.    Bladder  normal. 

TABLE  VII.— OPERATIONS  FOR  TUBER- 

PERFORMEB    BY 


Year. 


No. 


Initials. 


T.  S. 


T.  S. 


1888 


J.  M. 


1889 


Mr.  G. 


Sex. 


Male. 


Male. 


Female. 


Male. 


Age. 


28 


28 


49 


27 


Leading  Symptoms. 


Haematuria  in  1886,  followed 
by  pain  in  left  loin  and 
testicle.  Frequency  of  mic- 
turition for  1  year.  Con- 
siderable swelling  in  left 
loin.  Pyuria.  Tubercular 
nodule  in  left  epididymis. 


Nephrotomy    had   been 

viously  performed. 
(For  symptoms,  v.  No.  1.) 


pre- 


Noticed  a  tumour  in  left  loin 
for  9  years.  Pain,  haema- 
turia, and  passage  of  gravel 
and  blood-clot.  Albumi- 
nuria and  pyuria.  A  large 
tender  swelling  present  in 
left  loin. 


Pain  in  right  renal  region  with 
slight  haematuria  and  small 
quantity  of  pus. 


CULOUS    DISEASE    OF    THE    KIDNEYS. 

MR.     HENRY    MORRIS. 


Date  op  Operation. 


Result. 


Remakes. 


Nephrotomy. 

Feb.  11th,  1888. 

L.  Kidney. 


Nephrectomy. 

May  9th,  1888. 

L.  Kidney. 


Nephrotomy. 

Sep.  29th,  1888. 

L.  Kidney. 


Nephrectomy. 

July  20th,  1889. 

R.  Kidney. 


Recovered. 


Died 
May  12th! 


Recovered 
from  opera- 
tion, but  died 
on  Oct.  28th 
from  tubercu- 
lar cystitis 
and  pyelitis. 


Recovered 
from  opera- 
tion, but  died 
on  Sep.  9th 

owing  to 
disease  of  the 
other  kidney. 


The  kidney,  which  was  much 
enlarged,  was  incised,  and  3 
oz.  of  pus  escaped.  The  pelvis 
was  large  and  sacculated ,  and 
the  wound  was  drained,  re- 
covered with  a  sinus,  and 
subsequently  nephrectomy 
was  performed.    ( V.  No.  2.) 


The  kidney  was  much  enlarged 
and  contained  tubercular  ab- 
scesses. P.M.,  no  injury  to 
peritoneum  or  other  organs. 
The  opposite  kidney  was 
fatty  and  congested,  and 
tubercle  was  found  in  the 
other  organs  of  the  body. 
There  was  also  some  larda- 
ceous  disease  of  spleen  and 
intestines. 

(For  previous  operation,  v.  No.l.) 


The  kidney  was  incised  and  a 
quantity  of  pus  escaped. 
P.M.,  the  left  kidney  was 
reduced  to  a  series  of  loculi 
containing  caseous  material, 
and  drained  by  a  nephrotomy 
wound.  Intense  cystitis,  and 
pyelonephritis  of  the  right 
kidney.  Caseation  of  retro- 
peritoneal glands.  Old  tu- 
bercle at  apex  of  lung. 


Capsule  very  adherent.  Tuber- 
cles scattered  over  surface  of 
kidney,  and  several  patches 
of  diseased  tissue  in  the  kid- 
ney substance.  P.M.  made 
in  the  country;  the  left  kid- 
ney was  found  to  be  in  an 
advanced  state  of  cystic  de- 
generation.    ?  Polycystic. 


242     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII. 


Yeah. 


1890 


1890 


1890 


1892 


No. 


Initials. 


A.  A. 


c.  w. 


c.  w. 


A.F. 


Sex. 


Female. 


Male. 


Male. 


Male. 


Age. 


27 


24 


24 


28 


Leading  Symptoms. 


Pain  in  left  loin  for  3  years. 
Great  frequency  of  mictu- 
rition. Rounded,  fluctu- 
ating swelling  in  left  lum- 
bar region. 


Pain  in  left  lumbar  region  for 
7  years.  Tenderness  over 
left  kidney.  Albuminuria 
and  pyuria. 


Nephrectomy  on  account  of 
fistula  and  hectic  tempera- 
ture. 

( V.  No.  6.) 


Piepeated  attacks  of  pain  in 
right  loin  for  4  years. 
Frequency  of  micturition. 
Albuminuria,  pyuria,  and 
heematuria.  Some  tender- 
ness in  right  loin. 


TABLE  VII.— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     243 


Date  of  Operation. 

Result. 

Remarks. 

Nephrectomy. 

Died 

A  perinephric  abscess  and  large 

May  23rd,  1890. 

May  27th. 

areas  of  tuberculous  disease 

L.  Kidney. 

of  the  kidney  were  found. 
Patient  died  from  suppres- 
sion of  urine.  P.M.,  the 
right  kidney  was  in  an 
advanced  stage  of  dis- 
ease and  the  pyramidal 
substance  was  almost  de- 
stroyed. 

Partial  resection. 

Recovered. 

Kidney  drawn  out  on  to  loin. 

Nov.  28th,  1890. 

Several  abscesses  were  found 

L.  Kidney. 

in  the  cortex.  These  were 
opened  and  erased,  and  the 
kidney  was  incised  through 
its  convex  border  and  ex- 
plored. The  kidney  was  re- 
moved on  Dec.  20th,  owing 

Nephrectomy. 

Dec.  20th,  1890. 

L.  Kidney. 


Erasion  of  six  tuberculous 

abscesses. 

April  8th,  1892. 

R.  Kidney. 


Recovered. 


Recovered. 


to  persistence  of  a  discharg- 
ing sinus  and  a  hectic  tem- 
perature. 
(For    nephrectomy,     v.     same 
table,  No.  7.) 


The  kidney  was  much  enlarged, 
weighing  11^  oz.,  and  studded 
throughout  with  small  tuber- 
cvdar  abscesses.  The  infundi- 
bulum  of  the  ureter  contained 
a  quantity  of  pus,  and  the 
walls  were  covered  with  a 
fungating  granulomatous 
growth.  The  wound  healed, 
and  patient  was  known  to  be 
quite  healthy  and  well  in 
1893. 

(For  previous  nephrotomy,  v. 
same  table,  No.  6.) 


Six  saccules  were  found  in  the 
kidney,  containing  chalky 
purulent  material.  This 
material  was  scraped  out  and 
the  abscess  cavities  washed 
out  with  perchloride  of  mer- 
cury and  iodoform.  Wound 
healed  well,  and  patient  was 
known  to  be  well  in  Sept., 
1896. 


244     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII. 


Yeah. 


No. 


1892 


1892 


1893 


10 


11 


Initials. 


P.  J.        Male, 


Sex. 


Mrs.  R. 


Miss  J. 
(p) 


Female. 


Female, 


Age. 


35 


24 


Leading  Symptoms. 


In  1881  a  nodule  in  epididy- 
mis ulcerated,  but  finally 
healed.  After  this  he  had 
an  attack  of  cystitis  with 
hsematuria.  In  1886  an 
acute  attack  of  liEematuria, 
which  disabled  him  for 
12  months.  Frequency  of 
micturition  for  4  years. 
Acute  pain  in  right  lumbar 
region  since  1891.  Urine 
contained  a  large  quantity 
of  pus. 


An  invalid  for  16  years ;  a 
great  deal  of  pain  in 
the  back  ;  an  intermittent 
swelling  occurred  in  left 
loin.  General  loss  of 
energy  and  despondency, 
and  had  had  epileptiform 
convulsions  on  several  oc- 
casions. Urine  contained 
pus  and  a  little  blood. 


Pain  very  severe  at  times  ; 
frequency  of  micturition 
and  pyuria.  Duration  15 
months. 


TABLE  VII.— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     245 


Date  of  Operation. 


Kesult. 


Hem  auks. 


Nephrotomy. 

May  23rd,  1892. 

R.  Kidney. 


Nephrectomy. 

Aug.  16th,  1892. 

L.  Kidney. 


Nephrectomy. 

March  0th,  1893. 

L.  Kidney. 


Recovered 
from  opera- 
tion, but  died 
.subsequently 
from  tubercu- 
losis of  oppo- 
site kidney 
and  lungs. 


Recovered 

from 
operation. 

Died 

Sept.  18th, 

from  uraemia. 


Recovered. 


The  right  kidney  was  explored 
and  brought  to  the  surface. 
It  was  nypertrophied  and 
lobulated.  An  incision  into 
it  failed  to  reveal  any  definite 
disease.  The  kidney  was  su- 
tured and  the  wound  closed. 
On  June  7th  the  wound  had 
healed,  but  the  urine  still 
contained  pus  and  blood. 
The  patient  still  continued 
to  complain  of  pain  in  the 
right  side,  and,  becoming- 
much  worse,  he  sank  and 
died  on  June  13th.  P.M. 
Recent  miliary  tubercles 
throughout  both  lungs  and 
old  scars  at  apices.  The  left 
kidney  was  transformed  into 
a  multilocular  cyst  with  case- 
ous contents,  and  the  ureter 
was  blocked  by  tubercular 
deposits.  The  right  kid- 
ney showed  the  healed  in- 
cision, but  otherwise  was 
healthy. 


The  kidney  was  converted  into 
a  hollow  sac  with  scarcely 
any  secreting  structure  left. 
After  operation  the  urine 
still  retained  the  same 
characters,  thus  showing  the 
other  kidney  to  be  diseased. 
Wound  healed  well,  but  on 
Sept.  1st  she  had  a  severe 
attack  of  convulsions.  These 
subsided  and  the  patient  was 
able  to  go  home,  but  she  died 
on  Sept.  18th._  P.M.  Right 
kidney  was  in  a  very  ad- 
vanced state  of  hydrone- 
phrosis. 


Kidney  enlarged  and  com- 
pletely disorganised  by  tu- 
bercular abscesses.  Wound 
healed  by  first  intention, 
but  subsequently  two  shal- 
low sinuses  formed   in   the 


246     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII. 


Yeae. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1893 


12 


E.N. 


Female. 


33 


1893 


1894 


13 


14 


Miss  N. 
(?) 

J.  D. 


Female. 


Female. 


1894 


15 


1895 


1895 


J.  S.     !  Female. 


16 


17 


Mrs.  B. 
(P) 


G.  R 


26 


13 


Female. 


Female. 


28 


Frequency  of  micturition  for 
one  year.  Dull  pain  in 
left  lumbar  region  for  one 
month.  A  large  firm 
tumour  present  in  left  lum- 
bar region  Albuminuria, 
pyuria,  and  hematuria. 

Pain  and  frequency  of  mictu- 
rition. 


Tumour  in  right  loin,  varying 
in  size.  Pain.  Albumin- 
uria, pyuria,  and  haema- 
turia.  The  left  kidney  had 
been  previously  operated 
on  by  another  surgeon  for 
calculus,  and  a  lumbar 
fistula  followed. 


Frequency  of  micturition  and 
incontinence  for  7  months. 
Some  albumen,  pus,  and 
blood  in  urine.  No  pain 
in  either  loin.  It  was  in- 
tended to  explore  each  kid- 
ney separately,  as  bladder 
examination  afforded  no 
help. 


Attacks  of  pain  in  left  loin 
for  2  years.  Pyuria  and 
frequent  hematuria. 


Pain  for  some  years  in  right 
loin.  Albumen,  pus,  and 
occasionally  blood  in  the 
urine.  Rounded  tumour 
in  the  right  loin. 


TABLE  VIL— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     247 


Date  of  Operation. 


Result. 


Remarks. 


Nephrectomy. 

March  14th,  1893. 

L.  Kidney. 


Nephrectomy. 

June  22nd,  1893. 

L.  Kidney. 

Partial  resection. 

Feb.  20th,  1894. 

K.  Kidney. 


Nephrotomy. 

June  22nd,  1894. 

R.  Kidney. 


Partial  resection. 

Jan.  22nd,  1895. 

L.  Kidney. 


Nephrotomy. 

Jan.  25th,  1895. 

R.  Kidney. 


Recovered. 


Caseous  tuberculous  nodules  in 
the  kidney.  The  infundi- 
bulum  of  the  ureter  was 
filled  with  pus.  Wound 
healed  well. 


Died  July  1st. 


Recovered. 


A  cyst  and  a  tubercular  abscess 
of  the  kidney  were  opened 
and  excised ;  the  kidney 
wound  was  sutured.  Wound 
healed  without  a  fistula. 
Subsequently  I  closed  the 
left  lumbar  fistula  by  ex- 
cising its  renal  as  well  as  its 
parietal  track.  The  sinus 
opened  again  about  one  year 
later. 


Died  An  exploration  of  bladder  had 

June  24th.  previously  been   made  with 

negative  result.  The  kidney 
was  brought  on  to  loin  and 
explored  through  an  incision  in  its  convex 
border,  _  but  nothing  abnormal  was  found. 
The  incision  in  the  kidney  was  closed  with  cat- 
gut sutures.  Constant  vomiting  followed  the 
anaesthetic,  and  suppression  of  urine  occurred, 
and  patient  died.  P.M.  There  was  tuberculous 
disease  of  the  left  kidney,  and  a  fistulous 
opening  from  the  ureter  into  the  vagina. 

Recovered.  The  kidney  was  exposed,  and  3 
wedges  of  diseased  paren- 
chyma were  excised,  and  the 
kidney  substance  brought 
together  by  catgut  sutures. 
Recovered.  Is  well  at  the 
present  time. 


Recovered. 


The  kidney  was  enlarged,  and 
on  incising  the  convex  border 
a  quantity  of  pus  was  evacu- 
ated. The  pelvis  was  much 
dilated,  but  no  stone  was  felt. 
As  the  renal  sac  kept  refilling, 
nephrectomy  was  performed. 

( V.  No.  18.) 


248     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII. 


Year. 


No. 


Initials. 


Sex.  Age. 


Leading  Symptoms. 


1895 


18 


G.K. 


Female. 


1895 


19 


M.  C.  S. 


Female. 


1896 


20 


A.  C. 


Female. 


1896 


21 


A.  C. 


Female. 


44 


33 


33 


Persistence  of  symptoms  after 
previous  nephrotomy  (v. 
No.  17). 


Large  movable  tumour  in  left 
hypochondrium,  which  had 
been  first  noticed  5  years 
previously,  and  had  been 
long  treated  as  a  floating- 
kidney.  Latterly,  much 
pain  in  the  left  side.  Urine 
clear,  acid,  and  free  of  al- 
bumen. 


Pain  and  frequency  of  mic- 
turition for  11  years. 
Symptoms  followed  a 
strain.  Swelling  in  left 
lumbar  region  first  noticed 
in  1895. 


Swelling  in  the  left  loin  after 

a  previous  nephrectomy. 
(V.  No.  20.) 


TABLE  VII.— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     249 


Date  of  Operation. 


Kesult. 


Remarks. 


Nephrectomy. 

March  9th,  1895. 

R.  Kidney. 


Nephrectomy. 

Aug.  6th,  1895. 

L.  Kidney. 


Nephrectomy. 

March  11th,  1896. 

L.  Kidney. 


April  10th,  1896. 

Ureterectomy  and  removal 

of  renal  capsule. 


Recovered. 


Died 

Aug.  8th. 

Emphysema, 

bronchitis,  and 

hypostatic 

congestion  of 

both  lungs. 


Recovered. 


Recovered. 


An  exploratory  abdominal  in- 
cision was  first  made,  and 
the  left  kidney  found  to  be 
normal.  The  right  kidney 
was  then  removed  through  a 
lumbar  incision.  Wound 
healed  well,  and  patient  re- 
ported herself  quite  well  in 
June. 

(For  previous  nephrotomy,  v. 
No.  17.) 

The  kidney  was  very  large, 
dilated,  and  pouched,  and 
contained  a  large  quantity 
of  pale-green  caseous  ma- 
terial. The  kidney  substance 
was  almost  entirely  de- 
stroyed. The  ureter,  which 
was  filled  with  calcareous 
matter,  was  traced  down 
and  ligatured  4  inches  below 
the  kidney.  The  patient 
was  very  sick  after  the 
anaesthetic,  and  died  on 
Aug.  8th.  P.M.  Wound 
healthy,  no  injury  to  peri- 
toneum. Right  kidney  pale, 
but  not  enlarged. 

{Lancet,  Jan.  1st,  1898,  p.  18.) 

The  kidney  was  much  enlarged, 
and  filled  with  caseous  pus. 
It  was  shelled  out  of  its  cap- 
sule and  removed.  There  was 
a  subsequent  swelling  in  the 
loin,  necessitating  removal  of 
capsule  and  part  of  ureter. 

(See  Lancet,  Jan.  1st,  1898, 
p.  19.)     (V.  No.  21.) 


The  kidney  had  previously  been 
shelled  out  of  its  capsule 
and  removed.  It  was  now 
found  that  the  capsule  had  healed  where  it  had 
been  incised  for  the  enucleation  of  the  kidney, 
but  had  become  greatly  distended  with  blood- 
coloured  serum.  The  capsule,  which  was  calcified, 
was  dissected  out ;  and  4  inches  of  the  ureter, 
which  was  much  thickened,  were  also  excised. 
Wound  healed  well. 
(Lancet,  Jan.  1st,  1898,  p.  19.  For  previous 
nephrectomy,  v.  No.  20.) 


250     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII. 


Year. 


1896 


1896 


1896 


189- 


1897 


No. 


22 


23 


24 


25 


26 


Initials. 


Sex. 


E.  C. 


E.K. 


E.  R. 


F.  B. 


Mr.  P. 


Female. 


Female. 


Female. 


Female. 


Male. 


Age. 


29 


28 


28 


42 


24 


Leading  Symptoms. 


Frequency  of  micturition,  and 
dull  pain  in  the  left  loin. 
Some  enlargement  and 
tenderness  of  left  kidney. 
Nephropexy  had  been  pre- 
viously performed  on  the 
right  kidney. 


Pain  in  right  loin  for  4  years. 
Albumen  and  a  little  pus 
in  the  urine.  Swelling  in 
right  loin.  Nephropexy 
had  been  previously  per- 
formed on  the  right  kid- 
ney by  another  surgeon, 
There  was  also  pain, 
tenderness,  and  distinct 
bulging  in  the  left  loin. 

Swelling  in  right  loin. 

(For    further    symptoms,    v. 

No.  23.) 


Frequency  of  micturition  and 
attacks  of  pain  in  right 
loin.  Renal  tumour. 
Pyuria,  hematuria,  and 
albuminuria. 

The  upper  part  of  the  left 
kidney  had  been  previously 
removed  for  tuberculous 
disease  by  another  surgeon 
in  1897.  Sinus  remained. 
Micturition  frequent. 
Pyuria  and  tubercle  bacilli 
in  the  urine.  Tenderness 
all  along  course  of  left 
ureter. 


TABLE  VIL— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     251 


Date  of  Operation. 


Partial  resection. 
July  29th. 
L.  Kidney. 


Result. 


Remabks. 


Recovered. 


Nephrotomy. 

Oct.  28th,  1896. 

L.  Kidney. 


Nephrotomy. 

Nov.  18th,  1896. 

R.  Kidney. 


R.  Nephrectomy. 
March  1st,  1897. 


Nephro-ureterectomy. 

Sept.  21st,  1897. 

L.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


The  kidney  was  enlarged,  and 
contained  several  caseating 
foci,  which  were  excised, 
and  the  incisions  into  the 
kidney  were  sutured.  The 
wound  healed,  but  the  pa- 
tient had  a  high  tempera- 
ture and  occasional  rigors 
for  some  weeks  after  the 
operation. 

(Nephrectomy  was  subsequently 
performed  in  1897,  v.  No.  28.) 

Two  abscesses  were  found  in  the 
convex  border  of  the  kidney. 
They  contained  caseous  mat- 
ter, and  were  thoroughly 
scraped  out.  Wound  healed 
well. 

(For  subsequent  operation  on 
the  right  kidney,  v.  No.  24.) 


The  kidney  was  enlarged  and 
sacculated,  and  contained 
about  8  oz.  of  clear  fluid. 
The  kidney  was  drained,  and 
eventually  the  wound  healed 
well. 

(For  previous  operation  on  the 
left  kidney,  v.  No.  23.) 

Kidney  distended  and  contained 
a  great  deal  of  pus  in  separate 
loculi. 


The  kidney  was  puckered  and 
invaded  throughout  by  tuber- 
culous abscesses.  The  whole 
ureter  as  far  as  the  vesicula; 
seminales  was  excised ;  it 
was  thickened  and  tortuous, 
and  filled  with  caseous  and 
purulent  fluid.  Wound  healed 
well  ;  but  later  on  the  scar 
broke  down  and  some  liga- 
tures came  away,  after  winch 
the  wound  again  commenced 
to  close. 

( V.  Lancet,  Jan.  1st,  1898.) 


252     TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.— TABLE  VII 


Year. 


1897 


1897 


No. 


27 


28 


Initials. 


Mrs.  C. 


E.  C. 


Sex. 


Female. 


Female. 


Age. 


27 


30 


Leading  Symptoms. 


Frequent  micturition.  Pain 
in  left  loin  with  frequent 
attacks  of  hematuria  and 
pyuria  for  7  years.  Pain 
got  much  more  frequent, 
and  there  was  some  fever. 


small  sinus  in  left  loin, 
following  an  abscess,  which 
formed  and  opened  7 
months  after  recovery 
from  previous  operation. 


TABLE  VIL— TUBERCULOUS  DISEASE  OF  THE  KIDNEYS.     253 


Date  of  Operation. 


Result. 


Remarks. 


Nephro-ureterectomy. 

Oct.  28th,  1897. 

L.  Kidney. 


L.  Nephro-ureterectomy. 
Nov.  17th,  1897. 


Recovered. 


Recovered 

from 

operation,  but 

died  Dec.  21st, 

after  severe 

haemoptysis, 

from  tubercle 

of  lungs  and 

peritoneum. 


The  kidney  and  part  of  ureter 
were  excised.  The  kidney 
was  small  and  very  much 
atrophied.  Made  a  good  re- 
covery, and  wrote  in  1898 
saying  she  was  in  perfect 
health. 

The  sinus  was  found  to  lead 
behind  the  kidney  into  a 
cavity  situated  in  the  left 
iliac  fossa.  The  kidney  was 
small  and  markedly  cystic, 
with  very  little  secreting 
substance.  P.M.  A  retro- 
peritoneal collection  of  pus. 
Tubercles  in  lungs  and  peri- 
toneum. An  ulcer  in  the 
bladder.  Right  kidney  small 
and  _  contained  some  gritty 
particles. 

(For  previous  operation,  v. 
No.  22.) 


TABLE    VIII. 


-NEPHRECTOMY    FOR 

PERFORMED    BY 


Year. 


1894 


1895 


No. 


Initials. 


Sex. 


Mrs.  B. 


Mrs.  F. 


Female. 


Female. 


1895 


1897 


J.  M. 


Mrs.  T. 


Male. 


Female.        40 


Age. 


35 


20 


Leading  Symptoms. 


Nephrectomy,  on  account  of 
renal  fistula,  the  result  of 
afprevious  nephrotomyper- 
formed  by  another  surgeon. 

Illness  first  began  after  a  mis- 
carriage in  1892.  Soon 
after  an  ovarian  cyst 
formed,  which  was  tapped 
through  the  vagina,  and 
afterwards,  in  1894,  an 
ineffectual  attempt  was 
made  to  extract  the  tu- 
mour through  an  abdo- 
minal incision.  A  few 
weeks  later  an  abscess  ap- 
peared in  relation  to  the 
kidney,  and  this  was 
opened  by  an  incision  in 
the  loin.  The  above  ope- 
rations were  performed 
abroad,  and  a  few  months 
afterwards  the  scar  in  the 
loin  broke  clown  and  pus 
was  discharged. 

Continuing  hematuria  after 

nephrotomy. 
(V.  Table  IV.,  No.  30.) 


One  attack  of  renal  colic 
about  1890.  Right  kidney 
enlarged.  Patient^sud- 
denly  taken  with  acute 
illness  in  fifth  month  of 
pregnancy.  High  tempera- 
ture (105°),  rapid  pulse. 
Moderate  amount  of  albu- 
minuria and  pyuria. 
Rigors.  Improved.  In- 
duction of  labour  at  7i 
months,  then  recovered 
and  remained  well  till 
catamenial  period  in 
February,  1897. 


FISTULA,    OR    OTHER    CAUSES. 

MR.    HENRY  MORRIS. 


Date  of  Operation. 


Eesult. 


Eemarks. 


July  19th,  1894. 
Nephrectomy. 


July  19th,  1895. 

Nephrectomy. 

R.  Kidney. 


Recovered. 


Recovered. 


Feb.  12th. 

Nephrectomy. 

R.  Kidnev. 


Feb.  16th,  1897. 

Nephrectomy. 

R.  Kidney. 


Died 
Feb.  13th 


Recovered. 


Wound  healed  well.  The  kid- 
ney was  small  and  saccu- 
lated. Is  perfectly  well  to- 
day. 

The  condition  was  one  of  pyo- 
nephrosis, the  result  of  pres- 
sure on  the  ureter  by  pelvic 
adhesions  consequent  on  the 
ovarian  tumour.  The  kidney 
was  small  and  granular.  The 
pelvis  and  calyces  were  much 
dilated,  and  the  secretory 
substance  was  much  dimin- 
ished. Microscopically,  there 
was  an  advanced  condition 
of  interstitial  nephritis.  Had 
been  previously  operated 
upon  by  Vulliet  of  Geneva 
and  Kocher  of  Berne.  Is 
perfectly  well  at  present 
time.  Temperature  clay  pre- 
vious to  operation  105° ;  two 
hours  after  nephrectomy, 
normal. 

The  patient  was  very  collapsed, 
and  died  the  day  after  opera- 
tion. RM.  No  injury  to 
peritoneum.  R.  ureter  nor- 
mal, L.  kidney  pale. 

Kidney  enlarged  and  solid.  On 
incision  there  was  no  pus, 
but  numerous  deposits  of 
streaked,  creamy  appearance, 
the  size  of  small  marbles. 
Recovered  very  rapidly,  and 
remained  well  till  December, 
1897,  when  the  left  kidney 
was  threatened  by  fresh 
pregnancy.  Labour  was  in- 
duced, since  which  fever, 
pain,  and  pyuria  have  ceased, 
and  she  is  now  well  again. 


256      NEPHRECTOMY   FOB    FISTULA,    ETC.— TABLE    VIII. 


Year. 


1897 


No. 


Initials. 


Mrs.  D. 


Sex. 


Female. 


Age. 


41 


Leading  Symptoms. 


Nephropexy  on  right  kidney 
in  April,  1896.  Wound 
healed  and  remained 
sound  for  a  time,  but  later 
on  some  sutures  came 
away  and  a  fistula  formed. 
After  the  termination  of  a 
pregnancy  in  1897  patient 
became  extremely  ill.  High 
fever,  rigors.  Albumin- 
uria and  pyuria. 


TABLE    VIII.— NEPHRECTOMY   FOB    FISTULA,    ETC.      257 


Date  of  Operation. 


Result. 


Remarks. 


June  2nd,  1897. 

Nephrectomy. 

R.  Kidney. 


Died  June  3rd. 


The  patient  was  evidently 
suffering  from  septic  absorp- 
tion, after  convalescing  from 
her  confinement.  Nothing 
to  explain  this  illness  could 
be  detected  clinically  either 
about  the  pelvic  organs  or 
the  fistula,  but  it  was  thought 
advisable  to  explore  the  sinus. 
This  was  done,  and  the  kidney 
was  removed.  The  kidney 
was  very  friable,  and  showed 
numerous  small  foci  of  sup- 
puration, which  had  the  dis- 
tinction of  an  ascending 
nephritis.  Microscopically, 
the  specimen  showed  acute 
diffuse  nephritis.  No  P.M. 
was  obtained.  This  kidney 
had  the  same  morbid  char- 
acters as  that  in  Case  4  in 
this  table.  The  opposite 
kidney  was  most  likely  in 
the  same  stage. 


TABLE   IX.— OPERATIONS    FOR 

PERFORMED    BY 
A.  Ketroperitoneal  tumour  connected  with  kidney. 

A. 


Year. 


1897 


No. 


Initials. 


Mrs.  B. 


Sex. 


Female. 


Age. 


71 


Leading  Symptoms. 


Lump  noticed  for  a  few  days 
in  right  side  of  abdomen. 
Some  symptoms  of  consti- 
pation and  vomiting  had 
suggested  the  possibility 
of  intussusception. 


B. 


1893 


1893 


Mrs.  C.    Female 


F.  T. 


Male. 


37 


21 


A  large  painful  swelling  in 
left  side  of  abdomen. 


Large,  rapidly  growing  tumour, 


TUMOURS    OF    THE    KIDNEY. 

MR.     HENRY    MORRIS. 

B.  Cystic  disease  of  kidneys.  C.  Malignant  disease  of  kidneys. 


Date  op  Operation. 


Result. 


Remarks. 


Nephrectomy. 

June  12th,  1897. 

E.  Kidney. 

Excision  of  a  large 

perirenal  lipoma. 


Recovered. 


On  April  15th  laparotomy  was 
performed,  and  a  retroperi- 
toneal tumour  connected 
with  the  kidney  was  found. 
On  June  1st  the  tumour 
and  kidney  were  taken  out 
through  a  lumbar  incision. 
The  bulk  of  the  tumour 
shelled  out  well,  but  a  large 
part  of  it  was  very  adherent 
to  the  top  of  the  kidney.  It 
was  found  impossible  to  re 
move  the  tumour  without 
also  removing  the  kidney. 
The  tumour  proved  to  be  a 
large  retroperitoneal  lipoma. 

March,  1898. — There  are  indica- 
tions of  a  recurrence,  though 
patient  is  well  and  free  of 
pain. 


Nephrectomy. 

July  2nd,  1893. 

L.  Kidney. 


Nephrectomy. 
Aug.  18th,  1893. 


B. 

Recovered . 


Died 
Aug.  20th 


The  kidney  was  polycystic,  and 
was  removed.  Wound  healed 
well,  but  later  on  symptoms 
appeared  in  the  other  kid- 
ney. 

(For  second  operation,  v.  No.  4.) 


Nephrectomy  by  lumbar 
and  transperitoneal  method. 
Suffocated  from  vomit  from 
acute  dilatation  of  stomach 
48  hours  after  operation. 
The  kidney  was  one  of  con- 
genital cystic  disease.  No 
P.M.  allowed. 


260   OPERATIONS  FOE,  TUMOURS  OF  THE  KIDNEY.— TABLE  IX. 
B.  (continued) : — 


Year. 


No. 


Initials. 


Sex. 


Age. 


Leading  Symptoms. 


1893 


Mrs.  C. 


Female. 


37 


1894 


Mrs.  F. 


Female. 


43 


1898 


E.  C. 


Female. 


34 


Swelling,  which  was  very- 
painful,  in  region  of  right 
kidney.  Left  kidney  had 
been  previously  removed. 


Noticed  a  lump  in  right  side 
of  abdomen  since  Nov., 
1893.  Quite  painless.  A 
movable,  rounded,  lobu- 
lated  swelling. 


In  Nov.,  1897,  a  swelling  was 
first  noticed  in  the  left 
lumbar  region.  There  was 
some  pain  in  the  loins, 
but  not  very  acute.  At- 
tacks of  biliousness  and 
vomiting  have  been  fre- 
quent. There  was  a  large 
swelling  of  reniform  shape 
in  the  left  loin.  No  ten- 
derness.    No  albumen. 


0. 


1885 


1886 


H.  S. 


Mrs.  D. 


Male. 


51 


Female. 


70 


Swelling  and  hardness  in 
right  hypochondriac  region 
noticed  for  6  months.  Oc- 
casional pain.  A  large, 
firm,  rounded  swelling- 
movable  with  respiration 
was  felt. 

Subject  for  some  years  to 
bilious  attacks  and  pain 
in  region  of  gall  bladder. 
Pain  got  more  constant 
and  was  obliged  to  take  to 
bed.  A  tumour  had  been 
noticed  in  right  side  of 
abdomen  for  2  years,  and 
was  getting  larger.  Pro- 
gressive loss  of  flesh. 


TABLE  IX.— OPERATIONS  FOB  TUMOURS  OF  THE  KIDNEY.   261 
B.  (continued)  -.— 


Date  of  Operation. 


Result. 


Remarks. 


Nov.  9th,  1893.# 

Cysts  punctured  in 

11.  Kidney. 


Nephrectomy. 

May  3rd,  1894. 

R.  Kidney. 


Nephrectomy. 

Feb.  21st,  1898. 

L.  Kidney. 


Recovered. 


Recovered. 


Recovered. 


The  right  kidney  was  found  to 
be  in  a  condition  of  poly- 
cystic disease.  Two  large 
cysts  were  punctured  and 
the  tension  relieved.  The 
left  kidney  had  been  pre- 
viously removed — v.  No.  2 
in  this  table.  Subsequently 
died  from  extension  of  the 
disease. 

Kidney  excised  by  Langenbuch's 
and  lumbar  incision.  The 
opposite  kidney  examined, 
and  found  normal.  Rapid 
recovery.  Was  quite  well  in 
November,  1897.  The  tu- 
mour was  a  polycystic 
kidney.     Is  well  to-day. 

A  large  polycystic  kidney  was 
found  and  removed.  The 
ureter  was  catheterised,  and 
found  to  be  very  small  in 
diameter.  Three  inches  of' 
the  ureter  were  removed  with 
the  kidney.  Is  quite  well, 
and  passing  nearly  normal 
quantity  of  urine  of  good 
specific  gravity. 


L.  Nephrectomy. 
April  14th,  1885. 


Nephrectomy. 

April  15th,  1886. 

R.  Kidnev. 


c. 

Died 
April  15th. 


Died    in    18 

hours  from 

shock  of 

operation. 


A  large  sarcoma  of  the  supra- 
renal body  was  found  and 
excised,  with  the  kidney  at- 
tached to  it. 

(V.  Brit.  Med.  Journ.,  vol.  i., 
1893,  p.  2,  for  illustration  of 
tumour  and  report  of  case.) 

Kidney  removed  through  Lan- 
genbuch's incision.  The  kid- 
ney was  enlarged  to  three  or 
four  times  its  natural  size. 
The  growth  was  a  sarcoma 
with  numerous  cysts. 

(V.  Brit.  Med.  Journ.,  vol.  i., 
1893,  p.  2,  for  illustration  of 
tumour  and  report  of  case.) 


262    OPERATIONS  FOB  TUMOURS  OF  THE  KIDNEY.— TABLE  IX. 

C.  {continued)  :— 


Y.-AE. 


1888 


1892 


1894 


No. 


10 


11 


12 


Initials. 


Sex. 


Mr.  G.      Male.  55 


Miss  D. 


Mr.  C. 


Mrs.  C. 


Age. 


Female. 


Male. 


37 


43 


Leading  Symptoms. 


Tumour  in  the  right  loin. 


Pain  and  constipation  for  8 
months,  followed  by  dis 
covery  of  a  tumour. 


Female. 


1  fematuna  for  2  years.  Pro 
gressive  emaciation.  Pain 
first  came  on  in  March, 
1892,  and  a  tumour  was 
then  discovered.  The  liver 
was  also  enlarged. 


A  rapidly  growing  tumour  in 
left  hypochondrium  no- 
ticed for  a  few  weeks.  It 
is  movable  and  elastic.  No 
pain  or  tenderness. 


TABLE  IX.— OPERATIONS  FOB  TUMOURS  OF  THE  KIDNEY.   263 
C.  (continued)  .— 


Result. 


Remakes. 


Nephrectomy. 

March  18th,  1888 

R.  Kidney. 


Recovered. 


Nephrectomy. 

Oct.  15th,  1889. 

R.  Kidney. 


Recovered'. 


The  right  kidney  was  infiltrated 
with  cancerous  growth.  It 
was  removed  together  with 
the  adjacent  masses  of  cancer. 
New  growth  could  be  felt 
spreading  across  the  spine, 
upwards  behind  the  liver, 
and  down  into  pelvis.  Re- 
covered from  operation,  but 
died  in  following  June. 

(V.  Brit.  Med.  Journ.,  vol.  i., 
1893,  p.  2,  for  illustration  of 
tumour  and  report  of  case.) 

The  kidney  was  removed  by 
lumbar  and  lateral  abdominal 
incisions.  The  tumour  proved 
to  be  a  sarcoma  of  the  kidney. 
The  patient  subsequently 
died  from  malignant  disease 
of  the  ovary  and  liver  in 
summer  of  1892. 

(V.  Brit.  Med.  Journ.,  vol.  i., 
1893,  p.  2,  for  illustration  of 
tumour  and  report  of  case.) 


Nephrectomy. 

May  31st,  1892. 

R.  Kidney. 


Recovered. 


(V. 


Langenbuch's  incision.  The  liver 
was  found  studded  with 
white  nodules  of  new  growth 
resembling  cancer.  The  renal 
tumour,  however,  was  freely 
movable  and  easily  shelled 
out,  so  it  was  removed.  He 
recovered  rapidly,  was  re- 
lieved of  his  pain,  and  was 
living  8  months  after.  The 
tumour  proved  to  be  one  of 
the  supra  -  renal  capsule, 
which  had  encroached  upon  and  absorbed 
the  upper  part  of  the  right  kidney.  Its 
structure  resembled  the  medullary  part  of 
the  supra-renal  capsule. 
Brit.  Med.  Journ.,  vol.  i.,  1893,  p.  2,  for 
illustration  of  tumour  and  report  of  case.) 


March  28th,  1894. 
L.  Kidney. 


Recovered. 

Died  since  of 

recurrence. 


A  large  cyst  projected  from 
upper  end  of  kidney,  and 
was  with  difficulty  peeled 
away.  The  kidney  was  full 
of  small  cysts  containing 
gelatinous  materia],  and  was 
found  on  microscopical  ex- 
amination to  be  sarcomatous. 


264   OPERATIONS  FOR  TUMOURS  OF  THE  KIDNEY.- 

C.  {continued)  : — 


-TABLE  IX. 


Yeah. 

No. 

Initials. 

Sex. 

Age. 

1894 

13 

Mr.  B. 

Male. 

54 

1897 

14 

G.  D. 

Male. 

9 
months. 

1898 

15 

Mr.  D. 

Male. 

41 

Leading  Symptoms. 


In  Nov.,  1893,  commenced  to 
pass  clots  of  blood,  and  on 
one  occasion  had  retention 
for  a  short  time.  Lost 
flesh  rapidly.  A  large 
movable  tumour  in  the 
right  loin.  No  pain.  Some 
white  flakes  in  urine  and 
slight  albuminuria,  but 
otherwise  natural. 

Abdomen  large  since  birth, 
and  a  definite  tumour  no- 
ticed a  month  before  ad- 


Hasmaturia  at  intervals  of 
3  or  4  months  for  2  years. 
No  pain.  Swelling  in  right 
loin  detected  only  1  week. 
Losing  flesh,  and  hsema- 
turia  becoming  more 
severe. 


TABLE  IX.— OPERATIONS  FOB  TUMOURS  OF  THE  KIDNEY.    265 
C.  (continued)  .— 


Date  of  Operation. 


Result. 


Remarks. 


Sept.  13th,  1894. 

Nephrectomy. 

R.  Kidney.  . 


May  17th,  1897. 
R.  Nephrectomy. 


Jan.  20th,  1898. 
R.  Nephrectomy. 


Recovered. 

Died  since  of 

recurrence. 


Died  within 

a  few  hours 

of  shock, 

May  17th.  ' 


Recovered. 


Kidney  freed  from  its  surround- 
ings by  incision  into  loin, 
and  afterwards  extracted 
through  a  second  incision 
along  right  semilunaris.  The 
left  kidney  was  healthy.  The 
right  kidney  was  found  to  be 
the  seat  of  diffuse  sarco- 
matous growth. 


Incision  in  semi-lunar  line. 
The  pedicle  of  the  tumour 
ligatured  and  the  tumour 
removed.  It  was  found  to 
be  a  sarcoma  with  secondary 
deposits  in  the  retroperito- 
neal and  mesenteric  glands. 

Incision  in  right  linea  semi- 
lunaris and  diagnosis  verified. 
Through  right  lumbar  in- 
cision posterior  connections 
detached.  Nephrectomy 

completed   through  anterior 
incision. 


TABLE    X.— OPERA- 

PERFORMED    BY 


Year. 


1887 


No. 


Initials. 


T.  G.  W. 


Sex.  Age. 


Male. 


32 


1889 


T.  G.W. 


Male. 


34 


1893 


T.  L. 


Male. 


33 


Leading  Symptoms. 


Four  months  before  admission 
he  had  been  run  over  by  a 
van,  and  was  in  a  hospital 
for  3  weeks  with  ope  rib 
fractured  and  supposed 
internal  injury,  but  no- 
swelling  was  found.  On 
taking  a  walk  the  day  be- 
fore admission  he  was 
seized  with  severe  pain  in 
right  side  of  abdomen, 
passing  down  the  thigh. 
Vomiting  and  shivering 
also  occurred.  A  large 
fluctuating  swelling  was 
found  in  right  side  of 
abdomen,  which  was  in- 
creasing in  size. 

Admitted  for  swelling  in  right 
loin,  which  came  on  after 
a  urinary  sinus  in  the  loin 
had  closed.  The  sinus  was 
the  result  of  an  operation 
after  rupture  of  renal 
pelvis. 

(V.  No.  4.) 


No  definite  history  of  an 
injury  could  be  obtained, 
but  there  had  doubtless 
been  one  to  the  left  side. 
Had  been  confined  to  the 
house  for  5  weeks  on  ac- 
count of  general  debility 
and  pain  in  the  left  side 
extending  to  the  groin.  A 
large  tumour  was  felt  oc- 
cupying the  left  flank  and 
left  side  of  abdomen. 


TIONS    FOR    INJURY. 

MR.    HENRY    MORRIS. 


Date  op  Operation. 


Result. 


Remarks. 


Exploration. 

Oct.  27th,  1887 

R.  Kidney. 


Recovered. 


Exploration. 

June  1st,  1889 

R.  Kidney. 


Recovered. 


The  kidney  was  explored  through 
a  right  lumbar  incision.     As 
the  transversalis  fascia  was 
being     examined,    it    burst, 
and  100  oz.  of  blood-stained 
fluid  escaped.     A  large  rent 
was  felt  in  the  renal  pelvis. 
A  drainage-tube    was    put 
into  the  wound,  but  not  into 
the  kidney.     Recovered  with 
a  fistula.     The  kidney  was 
twice  explored  in  1889. 
( V.  Nos.  2  and  4  in  this  table.) 
(See  Edinburqh  Med.  Journ., 
Jan.,  1898.) 


The  old  scar  was  reopened. 
Kidney  could  not  be  defi- 
nitely distinguished,  the  man 
was  very  stout,  and  all  the 
tissues  in  the  loin  had  been 
very  much  altered  by  in- 
flammatory changes.  A 
drainage-tube  was  inserted 
into  the  track  of  the  old 
sinus.  In  July,  1894,  the 
sinus  was  still  open  and  a 
little  fluid  escaping  ;  but  the 
sinus  finally  closed. 

(For  previous  operation,  v.  Nos. 
1  and  4,  and  Clinical  Jour- 
nal, Aug.  1st.  1892.) 


Nephrectomy. 

July  8th,  1893. 

L.  Kidney. 


Recovered. 


After  dividing  the  muscles  the 
lumbar  fascia  bulged  con- 
siderably into  the  wound, 
and  as  soon  as  it  was  incised 
a  quantity  of  extravasated  blood  escaped.  About  4  pounds  of  blood- 
clot  was  removed  from  an  extensive  retro-peritoneal  space,  in  addition 
to  a  large  quantity  of  black  treacle-like  blood.  The  source  of  the 
haemorrhage  had  been  a  deep  rent  in  the  anterior  surface  of  the  lower 
half  of  the  kidney.  Kidney  was  removed  and  wound  healed  well. 
Patient  wrote  on  Nov.  23rd  saying  he  was  feeling  better  than  he 
had  done  at  any  time  during  recent  years. 

(V.  Clinical  Journal,  Aug.  1st,  1894.) 


268 


OPERATIONS    FOB    INJURY.— TABLE    X. 


Yeab. 


No. 


1897 


Initials. 


T.  G.  W. 


Sex. 


Male. 


Age. 


42 


Leading  Symptoms. 


A  fresh  abscess  formed,  and 
was  opened  through  the 
old  scar  ;  this  did  not  heal 
up,  and  patient  requested 
another  operation. 


TABLE    X.— OPERATIONS    FOB    INJURY. 


269 


Date  of  Operation. 


Result. 


Remarks. 


Ureterectomy. 

Nov.  15th,  1897. 

K.  side. 


Recovered. 


A  long,  curvilinear  incision  was 
made  as  for  nephro-ureterec- 
tomy,  and  a  most  careful  and 
thorough  search  instituted 
for  the  kidney,  but  only  a 
flattened,  fig-shaped  mass  of 
fibrous  tissue  was  found  in 
its  place.  The  ureter  was 
found  and  traced  nearly  up 
to  this  mass.  It  was  a  very 
slender  tube,  and  quite  closed 
at  its  renal  end.  As  a  little 
traction  was  being  made  on 
the  ureter,  it  tore  from  its 
connection.  The  patient 
made  a  good  recovery. 

(Edinburgh  Med.  Joum.,  Jan., 
1898.)' 

(For  previous  operations,  v. 
Nos.  1  and  2.) 


TABLE   XI.— COLLECTED    CASES 

CASES 


Year. 

No. 

Author. 

Sex. 

Age. 

Duration  and  Course  op 
Anuria. 

1870 

1 

GUERMONPREZ. 

— 

— 

Anuria. 

1882 

2 

BARDENHEUER. 

(Quoted  by 
Theleu.) 

Female. 

27 

Complete  anuria  for  2  days. 

1884 

3 

H.  MORRIS. 

Female. 

55 

Gradual    onset  of   anuria 
for    6    months,    which 
was     complete     for    6 
days  before  death. 

1885 

4 

LUCAS. 

Female. 

35 

Anuria  for  5  days  3  months 
after  a  nephrectomy. 

1885 

5 

MOLLIERE. 

Female. 

50 

Anuria  for  5  days. 

1886 

6 

LANGE. 

Male. 

30 

Anuria  through  obstruction 
of  right  ureter  2  months 
after  a  nephrolithotomy 
had  been  performed  on 
the  left. 

1886 

7 

ISRAEL. 

Female. 

50 

Anuria  for  6  days. 

OF    CALCULOUS    ANURIA. 

OPERATED     UPON. 


Opeeation. 


Result. 


Remaeks. 


Lumbar  nephrotomy. 


E  kidney  explored  and 
ureter  incised  and  fixed 
to  the  wound,  making  a 
permanent  fistula.  Cal- 
culus extracted  from 
upper  end  of  ureter. 

The  obstruction  was  de- 
tected at  lower  end  of 
ureter  when  the  bladder 
was  being  digitally  ex- 
plored. 


Nephrotomy.  Exploration 
of  kidney,  and  extrac- 
tion of  a  calculus  from 
the  pelvis  which  was 
obstructing  the  ureter. 

The  renal  pelvis  opened 
across  the  kidney  by 
thermocautery. 


R. 


and 


kidney  explored, 
some  concretions  were 
found  impacted  in  the 
upper  part  of  the  ureter 
and  removed. 


Pelvis  incised  and  stone 
extracted  from  upper 
end  of  ureter.  A  second 
calculus  was  also  found 
in  ureter  below  the 
other  and  extracted. 


Died  on  3rd 
day. 


Recovered. 


Died. 


Recovered. 


Recovered. 


Died   on  3rd 
day  after 
operation. 


Recovered 
with  fistula. 


Enormous  dilatation  of  left 
kidney  owing  to  a  stone 
blocking  the  ureter.  The 
right  kidney  was  absent. 

(Guermonprez  —  Soc.  Medico- 
Cliniqtie  de  Lille,  1870.) 

The  left  kidney  was  destroyed 
by  suppuration  secondary  to 
cystitis. 

{Centralbl.  fur  Chir.,  March 
25th,  1882.) 

The  impacted  calculus  could  not 
be  dislodged  by  means  of  the 
finger  in  the  bladder,  and  no 
more  extensive  operation 
could  be  performed  at  the 
time,  and  the  condition  of 
the  patient  did  not  allow 
any  subsequent  operation. 

The  patient  was  in  good  health 

5  years  after  the  operation. 
(Lancet,  1891,  i.,  p.  144.) 


(Lyon  Medicale,  1885,  p.  207.) 


(Medical  News,  Jan.  16th,  1886.) 


(Berl.  Uin.  Wock,  1886,  p.  870.) 


272    COLLECTED  CASES  OF  CALCULOUS  ANURIA.— TABLE  XL 


Year. 

No. 

1887 

8 

1887 

9 

1887 

10 

1888 

11 

1888 

12 

1889 

13 

1889 

14 

1889 

15 

1889 

16 

Author. 


PARKER. 


BERGMANN. 


CECI. 


CHAMPIQNNIERE. 


ISRAEL. 


RALFE  &  GQDLEE. 


H.  MORRIS. 


KIRKHAM. 


TORREY. 


Sex. 

Age. 

Male. 

13 

Male. 

54 

Female. 

42 

Male. 

49 

Female. 

26 

Female. 

63 

Male. 

58 

Female. 

43 

Duration  and  Course   of 
Anuria. 


Complete  anuria. 


Complete  anuria. 


Anuria. 


Anuria  for  13  hours. 


Anuria  for  5  days,  in  the 
course  of  renal  colic. 


Anuria  for  53  hours  after 
left  renal  colic. 

Total  suppression  of  urine 
for  9  days  before  opera- 
tion. The  attack  oc- 
curred immediately 
after  running  indoors  on 
the  onset  of  a  thunder- 
storm. Attack  con- 
sisted of  pain  in  right 
side  and  suppression. 
Previous  colic  on  left  (?) 
side,  but  date  uncertain. 

Anuria  for  5  days.  Cal- 
culus in  ureter  felt  just 
above  the  point  where 
it  crosses  the  external 
iliac  artery. 

Signs  of  uraemia  during 
course  of  a  pyone- 
phrosis of  left  kidney. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANURIA.     273 


Ol'EllATIOX. 


Right      lumbar      incision. 
Death  from  uraemia. 


Incision  of  renal  pelvis  and 
extraction  of  calculus 
from  upper  end  of 
ureter. 

Incision  of  ureter  through 
rectum,  and  extraction 
of  calculus. 

Incision  of  kidney  by 
thermocautery.  No 

stone  found. 

Pelvis  incised.  A  cal- 
culus found  obliterating 
upper  orifice  of  ureter, 
and  another  one  10 
cm.  lower  down.  Both 
extracted. 

Incision  of  ureter. 


Result. 


Remakes. 


Aug.     29th.      Explor. 
right  kidney. 


of 


Ureter  incised,  stone  ex- 
tracted, and  wound 
sutured.  The  stone 
was  reached  by  enlarging 
the  wound  in  the  loin. 

Stone  found  and  extracted 
at  mouth  of  ureter 
through  a  laceration. 
Kidney  and  pelvis 
drained. 
s 


Died. 


Recovered. 


Recovered. 


Recovered. 


Died  on  the 
9th  clay. 


Recovered. 


Died,  Aug. 
30th. 


Recovered. 


Recovered. 


Calculous  condition  of  R.  kidney 
with  a  little  gravel  in  the 
ureter.  Left  kidney  dis- 
organised. 

(Eoyal  Med.-Chir.  Soc,  1887, 
p.  253.) 

(Bergmann — Berl.  Mm.  Woch., 
1887,  p.  777.) 


(Biforma  Medica,  1887.    Quoted 
by  Vailhen.) 


Stone    expelled    spontaneously 

after  the  operation. 
(France  Medicate,  1888.) 

(Deutsch.  med.  Woch.,  1888,  p.  4.) 


(Ralfe  &  Godlee— B.  M. J.,  1889, 
p.  474.) 

Kidney  of  great  size  and  enor- 
mously congested.  Free 
incision  of  convex  border, 
the  margins  of  which  were 
stitched  to  loin  wound. 
A  few  ounces  of  urine 
escaped,  but  no  stone  found. 


(Lancet,  1889,  Vol.  i.,  p.  525.) 


(Amer.  J.  of  the  Med.  Sciences, 
1889.) 


274     COLLECTED  CASES  OF  CALCULOUS  ANURIA.— TABLE  XL 


Year. 

No. 

1890 

17 

1891 

18 

1891 

19 

1892 

20 

1893 

21 

1893 

22 

1893 

23 

1893 

24 

Author. 


Sex. 

Age. 

Male. 

60 

Male. 

17 

Female. 

45 

Male. 

54 

Female. 

63 

Female. 

52 

Duration  and   Course  of 
Anuria. 


CABOT. 


H.  MORRIS. 


TURNER. 


DESNOS. 


DUFFAU— 

largarosse. 


GANGOLPHE. 


H.  MORRIS. 


LEGUEU. 


Complete  anuria  for  seven 
days.  Previous  attacks 
of  colic. 


6  oz.  of  urine  passed  in 
3  days  after  operation 
of  nephrotomy  on  right 
kidney.  Impaction  of 
calculus  in  ureter  of 
opposite  side. 


Calculous  anuria,  with 
double  pyonephrosis. 

Anuria  for  7  days  follow- 
ing after  frequent  at- 
tacks of  colic  for  many 
years. 

Anuria  for  8  days. 


Urgent  symptoms  of  an- 
uria. 


Suppression  of  urine  for  6 
days  before  operation. 
Was  suffering__at  jthe 
time  of  operation  from 
bronchitis  and  asthma. 


Anuria  for  7  clays.  Marked 
vomiting  at  onset. 
Mind  clouded  towards 
the  end.  Previous  pain 
chiefly  on  right  side. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANURIA.     275 


Operation. 


Result. 


Remarks. 


Median  abdom.  explor.  R. 
ureter  appeared  normal 
— left  could  not  be  felt. 
Lumbar  incision  and 
explor.  of  left  kidney, 
but  nothing  found. 

Operation  Dec.  2nd.  In- 
cision made  into  con- 
vex border  of  right 
kidney  and  3  calculi 
extracted. 


Nephrotomy  on  both  sides. 


Nephrotomy. 

Calculi  found  and  urinary 

flow  re-established. 


Nephrotomy. 


Nephrotomy. 


Recovered. 


Oct.  6th,  1893.  R.  nephro- 
tomy. One  calculus 
and  several  phosphatic 
concretions  extracted 
from  pelvis  and  upper 
end  of  ureter. 

Nephrotomy,  R,  Incision 
into  convex  border. 
Some  urine  escaped. 
Several  calculi  in  pel- 
vis, one  of  which 
blocked  the  orifice  of 
the  ureter. 


Died  Dec.  4th. 


Died. 


Recovered. 


Death. 


Death  3  days 
after. 


Died   1  hour 

after 

operation. 


Died. 


9  gallons  of  urine  were  passed 
in  first  24  hours  after  opera- 
tion. 

{Boston  Med.  &  Surg.  Journal) 


P.M.,  the  right  kidney  was  in 
an  advanced  state  of  pyone- 
phrosis. The  left  was  con- 
verted into  a  multilocular 
sac  containing  a  calculus, 
and  another  calculus  was 
impacted  in  upper  part  of 
ureter. 

(JB.  M.  J.,  1891,  p.  852). 


(Annates  des  maladies  des  or- 
ganes  ge'nito-urinaires,  1892, 
p.  410.) 


(Annales  des  maladies  des  or- 
qanes  genito-urinaires,  1893, 
P-  77.) 

Pyonephrosis  on  right  side,  clue 

to  calculus.     L.  kidney  was 

a  collection  of  cysts. 
(Gangolphe  —  France  Medicate, 

1893,    p.    111.     Quoted    by 

Vailhen.) 

The  symptoms  before  the  fatal 
attack  had  been  attacks  of 
pain  in  the  right  loin,  ac- 
companied by  suppression 
of  urine,  bronchitis,  and 
asthma. 

(Memoire  sur  Vanurie  cal- 
culeuse,  1895.) 


276     COLLECTED  CASES  OF  CALCULOUS  ANURLA.—  TABLE  XL 


Yeae. 


1893 


1893 


No. 


25 


26 


1894 


AUTHOE. 


Sex. 


H.  MORRIS. 


VERNON. 


Age. 


Male. 


Male. 


63 


63 


27 


HIND. 

(Mr.  Morris  pre- 
sent at  opera- 
tion.) 


1894        28        DEMONS. 


Male. 


Male. 


55 


28 


DUEATION  AND    CoiJESE   OP 

Anueia. 


History  of  previous  pas- 
sage of  a  calculus.  Oct. 
24th,  an  attack  of 
haematuria,  followed 
by  partial  suppression 
for  36  hours.  On  Nov. 
2nd  suppression  again 
took  place,  and  lasted 
5  days. 


Anuria  for  3  days  follow- 
ing an  attack  of  fever, 
and  pain  in  loins  with 
pus  and  albumen  in  the 
urine. 


Suppression    for    6    days. 
Believed  by  operation. 


Anuria  for  12  days. 


TABLE  XL—COLLECTED  CASES  OF  CALCULOUS  ANURIA.     277 


Operation. 


Nov.  7th,  1893,  R.  kidney 
explored,  and  found 
very  large,  tough,  and 
hypertrophied.  Kidney 
incised  and  found  to 
be  sacculated,  and  an 
ounce  or  two  of  urine 
pent  up. 


Dec.  31st,  1893,  Nephro- 
tomy, R.  Kidney. 


Jan.  9th,  1894,  R.  ne- 
phrotomy and  ureter- 
otomy. Calculus  found 
blocking  ureter  at  its 
upper  end,  and  several 
small  stones  in  the 
pelvis  were  also  ex- 
tracted through  the 
same  incision  in  the 
ureter.  The  one  block- 
ing the  ureter  weighed 
7  grains.  One  also 
removed  from  kidney 
substance  by  incision 
along  convex  border 
which  weighed  36  grns. 

Nephrotomy  on  12th  clay. 


Result. 


Died      Nov. 
9th. 


Died. 


Died  58  hours 
after  the 
operation. 


Remarks. 


After  the  operation  large  quan- 
tities of  urine  freely  passed 
through  the  lumbar  wound 
up  to  the  time  of  death. 
P.M.,  right  kidney  in  ad- 
vanced state  of  chronic 
nephritis  and  dilatation, 
owing  to  previous  long- 
standing partial  obstruction 
in  ureter.  Left  kidney  en- 
tirely destroyed. 

The  right  kidney  was  incised, 
and  a  quantity  of  foul  urine 
and  pus  escaped.  After  the 
operation  there  was  some 
improvement  for  a  few  days, 
and  much  urine  was  secreted 
by  the  wound,  and  some  was 
passed  naturally.  Died  a 
week  after  operation.  P.M., 
suppuration  of  right  kidney, 
and  half-way  down  the  ure- 
ter a  phosphatic  stone  was 
impacted.  The  left  kidney 
was  completely  atrophied. 

{Brit.  Med.  Journ.,  i.,  1894,  p. 
1304.) 

Urine  freely  passed  immediately 
after  operation,  and  con- 
tinued to  death.  P.M.,  left 
kidney  a  mere  shell,  contain- 
ing 360  grains  of  calculous 
deposit. 

{B.  M.  J.,  May  5th,  1894,  p.  960.) 


Recovered.  For  2  months  after  operation 
the  urine  was  partly  passed 
through  the  wound  in  the  loin.  A  calculus  the 
size  of  a  bean  was  then  passed  through  the 
urethra,  and  after  this  the  fistula  rapidly  closed. 
{Annates  des  maladies  des  organes  gmito- 
urinaires,  1894,  p.  97.) 


278     COLLECTED  CASES  OF  CALCULOUS  ANURIA.— TABLE  XI. 


Year. 


No. 


Author. 


Sex. 


Age. 


Duration  and  CotTRSE  of 
Anuria. 


1894 


29 


1894 


1894 


1894 


1894 


30 


31 


32 


33 


POUSSON— 
DEMONS. 


POUSSON. 


JOUON   AND 
VIGNARD. 


KADIAU. 


SUTTON. 


Male. 


43 


Female. 


Female. 


Female. 


Male. 


42 


32 


58 


44 


1895 


1895 


1895 


34 


35 


POUSSON. 


H.  MORRIS. 


36 


LEGUEU. 


Female. 


Female. 


Male. 


38 


35 


Anuria  for  9  clays. 


Anuria  for  4  clays. 


Anuria  for  3  days. 


Anuria,  with  uraemic  symp- 
toms. 


Attacks  of  pain  in  left 
lumbar  region  for  29 
years.  Occasional  pas- 
sage of  gravel  and 
hasniaturia.  Sudden 
attack  of  pain  in  right 
loin  was  accompanied 
by  anuria.  Complete 
anuria  for  72  hours 
with  incomplete  anuria 
(5  oz.  passed)  for  next 
24  hours.  Refused  to  be 
operated  upon  earlier. 

Anuria, with  uraemic  symp- 
toms. 


Incomplete,  with  inter- 
mission, 18  days,  fol- 
lowed by  complete  sup- 
pression of  urine  for  4 
days,  due  to  impaction 
of  stone  in  left  ureter. 

Anuria  for  5  days. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANURIA.    279 


Operation. 


Result. 


Remarks. 


Nephrotomy  on  9th  day, 
and  some  gravel  re- 
moved from  upper  end 
of  ureter. 


Nephrotomy  on  4th  day. 


Nephrotomy.  Incision  into 
the  convex  border  of 
the  kidney.  Some  pus 
and  ixrine  escaped.  No 
stone  found. 


Died. 


Nephrotomy. 


June  24th,  1894,  R.  Kidney. 


Recovered. 


Recovered. 


Died  8  hours 

after 

operation. 


Died  June 
25th. 


Nephrotomy. 


Feb.  8th,  1895,  L.  Kidney. 
Stone  extracted  from 
ureter  and  another  from 
kidney  substance.  Large 
quantity  of  pus  present. 


Nephrotomy. 


Died  during 
operation. 


Died  2  hours 

after 

operation. 


Recovered. 


Urine  passed  by  urethra  after 

operation,  but  death  occurred 

in  24  hours. 
{Annates  des  maladies   des   or- 

ganes  genito-urinaires,  1894, 

p.  99.) 

Natural  flow  re-established  on 
the  7th  day  after  operation. 

(Annates  des  maladies  des  or- 
ganes  genito-urinaires,  1894, 
p.  101.) 

A  fistula  remained. 

(Annates  des  maladies  des  or- 

ganes  genito-urinaires,  1894, 

p.  688.) 


Both  ureters  found  obliterated 
by  calculi  near  their  entrance 
into  the  bladder.  (Medecine 
Moderne,  1894,  p.  1076.) 

R.  Kidney  very  congested  and 
a  stone  found  blocking  the 
upper  end  of  right  ureter. 
P.M.,  calculous  pyelitis  of 
the  left  kidney  and  obstruc- 
tion of  the  ureter  by  a  stone. 

(Middlesex  Hosp.  Reports,  1894, 
p.  187.) 


These     Donnadieu,    Bordeaux, 
1895.     Quoted  by  Vailhen.) 


This  was  the  third  operation. 
The  other  two  had  been  per- 
formed on  the  right  kidney, 
which  had  been  much  dis- 
eased by  the  presence  of 
stones  (see  Tables  I.  and  II.). 

Stone  extracted  from  the  ureter 
and  the  renal  wound  sutured. 
Recovery    without  a   sinus. 

(These  Donnadieu,  1895.) 


280     COLLECTED  CASES  OF  CALCULOUS  ANURIA.— TABLE  XL 


Year. 


No. 


Author. 


Sex. 


Age. 


Duration  and  Course  op 
Anuria. 


1895 


1895 


37 


38 


LEGUEU. 


LEGUEU. 


Male. 


Male. 


47 


54 


1895 


39 


LEGUEU. 


Female. 


22 


1895 


40 


DURET. 


Male. 


43 


1895 


41 


H.  MORRIS. 


Male. 


47 


1895 


42 


PARKIN. 


Male. 


56 


Anuria  for  6  days.  Sub- 
ject to  colic  for  many 
years.  No  ursemic 
symptoms. 

Anuria  for  6  days.  Symp- 
toms since  1891.  Ino 
urasmic  symptoms. 


Anuria  for  3  days.  Vomit- 
ing a  marked  symptom. 
Previous  passage  of 
stones. 


Intermittent  anuria  with 
convulsions  on  the 
third  day. 


Sinuses  resulting  from 
perinephric  abscesses, 
the  result  of  calculi, 
were  explored  on  June 
25th,  1895.  No  cal- 
culus found,  nor  could 
the  kidney  be  felt.  On 
the  26th,  anuria  set  in 
(5  oz.  were  passed  in 
24  hours).  On  the  28th 
a  catheter  was  passed, 
but  only  2  ozr— were 
drawn  off. 

Anuria  for  4  days.  Symp- 
toms of  calculi  in  both 
kidneys  for  some  years. 
On  Dec.  18th  he  had 
an  attack  of  pain  in  left 
loin,  accompanied  by 
total  suppression,  which 
lasted  for  4  days. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANURIA.     281 


Operation. 


Result, 


Remakes. 


Nephrotomy,  R.  Incision 
into  convex  border. 
Stone  found  impacted 
in  orifice  of  ureter. 


Nephrotomy,  L.  Incision 
into  lower  part  of 
kidney  substance.  Ex- 
plor.  of  pelvis.  Escape 
of  some  urine  and  ex- 
traction of  stone  from 
upper  end  of  ureter. 

Nephrotomy,  L.  Large 
amount  of  gravel  and 
some  small  calculi 
found.  Ureter  thick- 
ened. Incision  along 
convex  border  of  kid- 


ney. 


Nephrotomy. 


June  28th,  Laparotomy. 


Dec.    22nd,    Nephrotomy, 
L.  Kidney. 


Recovered. 


Died  soon 

after 
operation. 


Died  on  the 

day  of 
operation. 


Recovered. 


Died  June 
28th. 


Recovered. 


A  fistula  remained. 

(Annates  de  Guyon,  1895. 
Quoted  by  Vailhen  in  These, 
L'Anurie  Calculeuse,  1896, 
pp.  G7,  74,  and  76.) 

(Annates  de  Guyon,  1895. 
Quoted  by  Vailhen  in  These, 
L'Anurie  Calculeuse,  1896, 
pp.  67,  74,  and  76.) 


(Annales  de  Guyon,  1895. 
Quoted  by  Vailhen  in  These, 
L'Anurie  Calculeuse,  1896, 
pp.  67,  74,  and  76.) 


No  stone  found.  The  pelvis 
was  drained  and  the  urine 
was  again  passed  naturally. 

(Quoted  by  Vailhen  in  These, 
L'Anurie  Calculeuse,  1896, 
p.  18.) 

The  abdomen  was  explored,  but 
no  calculus  could  be  felt  in 
either  kidney.  P.M.,  cal- 
culous pyelitis  with  de- 
struction of  the  left  kidney 
and  chronic  parenchymatous 
and  interstitial  nephritis  of 
the  right  kidney. 

(Middlesex  Hosp.  Report,  1895, 
p.  178.) 


The  kidney  was  congested,  and 
an  incision  into  the  cortex 
caused  profuse  haemorrhage, 
which  required  plugging  to 
control  it.  The  pelvis  was 
then  opened  from  behind, 
and  a  large  conical-shaped 
calculus  removed  from  the 
upper  end  of  the  ureter. 

(Lancet,  Sep.  12th,  1896.) 


282     COLLECTED  CASES  OF  CALCULOUS  ANURIA.— TABLE  XL 


Year. 


No. 


Author. 


Sex. 


Age. 


Duration  and  Course  of 
Anuria. 


1896 


43 


CHEVALIER. 


1896 


1896 


44 


45 


CHEVALIER. 


ISRAEL. 


1896 


46 


(?) 


47 


1897 


48 


ISRAEL. 


DURET. 

(Reported  by 
Vailhen.) 


MACMUNN. 


Male. 


Anuria  for  6  clays. 


Female. 


Female. 


63 


Male. 


Male. 


42 


Male. 


35 


Anuria  for  14  days. 


Anuria  almost  complete 
for  6  days.  Uraemic 
symptoms  on  the  5th 
day. 


Anuria  for  6  days. 


Complete  anuria  for  2  days, 
which  was  gradually 
succeeded  by  a  free  flow 
of  urine,  but  complete 
anuria  again  suddenly 
set  in  on  the  6th  day, 
and  lasted  till  opera- 
tion, which  was  per- 
formed on  the  9th  day. 

Suppression  of  urine  for  2 
clays  after  repeated  at- 
tacks of  colic. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANUBLA.     283 


Operation. 


L.  Nephrotomy. 


R.  Nephrotomy. 


Exploration  of  right  kid- 
ney and  nreter. 


Exploration  of  kidney  and 
ureter. 


Exploration  of  kidney,  with 
negative  result. 


Eesult. 


Died. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Aug.  19th.    Both  kidneys     Died       Aug. 
operated    upon.      Left  26th. 

kidney  explored  and 
small  stone  felt  and  crushed,  but  not  ex- 
tracted. Right  kidney  opened  ;  stone  in 
ureter,  at  junction  of  infundibulum, 
found  and  removed.  No  urine  pent  up. 
Renal  pelvic  ureter  not  explored. 


Remarks. 


The  renal  function  was  restored, 
but  death  occurred  16  days 
after  from  tuberculosis  of  the 
lungs. 

(Quoted  by  Vailhen  in  These, 
L'Anurie  Calculeuse,  1896, 
p.  19.) 

Gravel  found  and  renal  function 

was  re-established. 
(Quoted  by  Vailhen  in  These, 

L'Anurie    Calculeuse,    1896, 

p.  19.) 

The  kidney  was  distended,  and 
a  stone  was  found  blocking 
the  ureter  about  2  cm.  below 
the  innominate  line.  The 
stone  was  extracted  through 
pelvis  of  the  kidney  and  the 
renal  wound  sutured. 

(Presse  Medicale,  April  4th, 
1896.) 

A  stone  was  found  tightly  im- 
pacted at  the  upper  end  of 
the  ureter.  The  kidney  was 
also  found  to  contain  stones, 
which  were  removed.  It  was 
later  on  proved  that  there  was 
only  one  kidney  existing  in 
this  case. 

{Presse  Medicale,  April  4th, 
1896.) 

The  kidney  was  very  much  en- 
larged, and  no  kidney  could 
be  felt  on  the  opposite  side, 
and  it  was  thought  there  was 
probably  only  one  kidney  in 
this  case. 

(These,  L'Anurie  Calculeuse,  by 
Vailhen,  1896,  p.  80.) 


Passed  20  oz.  urine  day  after 
operation,  but  less  on  the 
next  day,  and  after  that 
there  was  almost  complete 
suppression  till  he  died. 
(Unpublished.) 
Private  information. 


284     COLLECTED  CASE 8  OF  CALCULOUS  ANURIA.— TABLE  XL 


Year. 


1898 


No. 


49 


Author. 


H.  MORRIS. 


Sex. 


Female. 


Age. 


26 


Duration  and  Course  of 
Anuria. 


Dull  aching  pains  in  left 
loin  for  more  than  2 
years.  Typical  attack 
of  left  renal  colic  in 
Jan.,  1897,  followed 
afterwards  by  other 
attacks.  These  attacks 
were  often  accompanied 
by  temporary  suppres- 
sion of  urine,  which 
lasted  from  2  to  3  days, 
and  occurred,  latterly,  2 
and  3  times  in  a  fort- 
night. There  was  en- 
largement of  right 
kidney  which  felt 
very  hard,  and  was 
believed  to  contain  a 
calculus. 


TABLE  XL— COLLECTED  CASES  OF  CALCULOUS  ANURIA.    285 


Operation. 


Result. 


Rehaeks. 


Jan.  26th,  1898,  L.  nephro- 
lithotomy. 


Recovered. 


Kidney  very  enlarged  and  con- 
gested._  An  incision  was 
made  in  the  convex  border, 
and  through  it  a  stone  was 
extracted  from  the  renal 
pelvis. 

(V.  Table!.,  No.  35.) 


INDEX 


Abdominal  Hysterectomy.  (See  Hys- 
terectomy.) 

Abscess,  Perinephric,  82 

Anastomosis,  Uretero- ureteral,  32 

Anuria,  Calculous : 

Anatomy, Pathological,  of,  105 

Collected  Cusesof  (Tables),  270 

Diagnosis  of,  108 

Etiology  of,  92 

from  Polycystic  Disease,  110 

Prognosis,  104 

Symptoms  of,  98,  100,  102 

from  Traumatic  Anuria,  112 

Treatment,  113 

from  Uterine  Cancer,  110 

Bardenheuer's  Operation,  17 
Bovee's  Method  of  Anastomosis,  37 
Bryant's  Operation,  5 

Csecuni,  Rupture  of,  132 
Calculous  Anuria.      (See  Anuria.) 
Calculus.     (See  Renal  Calculus.) 
Cancer,  Uterine.  (See  Anuria  Calculous.) 

End-in-End  Method  of  Anastomosis,  33, 

38 
End-to-End  Method  of  Anastomosis,  32, 

33,  37,  38 
Excisions,  Partial,  11 

Fistula,  Nephrectomy  for  (Tables),  254 
Fistulas,  82-87 

Floating  Kidneys,  Painful,  Nephrectomy 
for,  4 

Gangrene,  129 
Grafting,  Ureteral,  40 

Hahn's  Operation  for  Fixing  Movable 
Kidneys,  7 

Hook's  Operation  by  Lateral  Implanta- 
tion, 33 

Hydronephrosis  in  Calculous  Anuria,  100 

Necessity  of  Conservative  Treat- 

ment, 25 

Ureterotomy  for,  15 

and  Pyonephrosis  (Tables),  232 

Hysterectomy,  Abdominal,  38 

Implantation,  Lateral,  33 

Omental,  34 

Injuries,  Nephrectomy  for,  4 

of  Ureter.  (See  Ureter,  Injuries  of.) 

Injury,  Operations  for  (Tables),  26G 
Irrigation  as  a  Substitute  for  Nephrec- 
tomy, 43 


Kidney,  Exploration  of,  116 

Floating,  4 

Movable,   Hahn's    Operation    for 

Fixing,  7 
Operations    for   Tumours    of  the 

(Tables),  258 
Tuberculous  Disease  of  the(  Tables), 

240 

Lateral  Implantation,  Methods  of,  33,  34 
Lumbar  Incision,  142 

Malignant  Disease,  Nephrectomy  for,  4 
Migratory  Calculi,  75-78 
Morris's  Operations,  Tables  of,  158  et  seq. 
Movable  Kidney,  Operations  for  ( Tables) , 

210 
Movable  Kidney,  Operations  for  Fixing. 

(See  Nephropexy.) 

"Negative  Exploration,"  46,  50 
"Nephralgia,"  49-53 
Nephrectomy,  3,  142 

for  Fistula,  254 

Opposition  in  France  to  use  of,  4 

for  Stone,  Cases  of  (Tables),  184  . 

Substitutes  for,  41 

Nephrolithotomy,  6 

Cases  of  (Tables),  158 

Nephropexy,  7 

Nephrorrhaphy .     ( See  Nephropexy. ) 

Nephrotomy,  5 

for  Stone,  Cases  of  (Tables),  168 

for  Tuberculous  Pyonephrosis,  5 

Obstruction,  Valvular,  18 

Omental  Method  of  Lateral  Implanta- 
tion, 34 

Operations,  Exploratory  (Tables),  192 

on  Kidney  and  Ureter,  116-126 

Convalescence,  125 

Renal,     performed    by     Moms, 

158  et  seq. 

Parametric  Inflammations,  63 

Partial  Excisions,  1 1 

Pelvis,  Renal,  Rupture  of,  130 

Perimetric  Inflammations,  63 

Plastic  Operations  by  Vesical  Grafting, 

Polycystic  Disease  and  Anuria,  110 

Puncture,  142 

Pyonephrosis  and  Hydronephrosis( Table), 

,  Tuberculous,  Nephrotomy  for,  5 

Quiescent  Calculus,  70-74 


288 


INDEX. 


Renal  Calculus : 

Anuria,  Calculous,  90 

■ Diagnosis  of,  108 

•■ Etiology  of,  92 

Hydronephrosis  in,  100 

Mistaken  Diagnosis,  50 

Pathological  Anatomy  of, 

105 
from     Polycystic    Disease, 

110 
— —   Prognosis  of,  104 

Spontaneous  Recovery,  104 

Symptoms  of,  97 

from  Traumatic  Anuria,  112 

Treatment  of,  113 

Urasmic  Stage,  102 

from  Uterine  Cancer,  110 

Calculi  which  do  not  cause  Symptoms, 

54 

Danger  of,  89 

Fistulas  caused  by,  82 

Migratory,  75 

Objections  to  early  Operations  for,  87 

Quiescent,  70 

Summary  of,  78 

Unsuspected,  53,  64,  66 
Operations,   Tables  of   Cases   per- 
formed by  Author,  158  et  seq. 
Surgery : 

Excisions,  Partial,  11 

History,  1 

Nephrectomy,  3 

Nephrolithotomy,  6 

Nephropexy,  7 

Nephrotomy,  5 

Ureter,  Operations  on  the,  15 

Resection  of  the,  22 

Wounds  of  the,  30 

Ureteral  Grafting,  40 

Ureterectomy,  27 

Uretero-ureteral  Anastomosis,  32 

Ureterotomy  for  Calculus,  16 

for  Stricture   and  Valvular  Ob- 
struction, 18 
Resection  of  the  Ureter,  22 
Retroperitoneal  Exploration,  117 
Ruptures,     127,     130,    132.      (See    also 

Ureter,  Injuries  of.) 

Stenosis,  Ureteral,  18 
Stricture,  Ureterotomy  for,  18 
Surgery,  Renal.     (See  Renal  Surgery.) 


Tables  of  Author's  Operations,  158  et  seq. 

Traumatic  Hydronephrosis,  130 

Tuberculosis,  Ureterectomy  for,  27 

Tuberculous  Disease  of  Kidney,  Opera- 
tion for,  240 

Tuberculous  Pyonephrosis,  Nephrotomy 
for,  5 

Turner's  Operation,  9 

Tumours,  131 

Unsuspected  Renal  Calculus,  53-70 
Urcemic  Stage  of  Calculous  Anuria,  102 
Ureter : 

Exploration  of,  116 
Injuries  of  : 
Causes  of,  133 

Contracted    ureter    with  hydrone- 
phrosis, 130 
Diagnosis  of,  140 
Pathology  of,  135 
Penetrating  Wounds,  129 
Prognosis  of,  141 
Ruptures,  127,  130,  132 
Subcutaneous,  128 
Subparietal,  129 
Surgical  Wounds,  127,  129 
Symptoms  of,  137 
Traumatic  hydronephrosis,  130 
Treatment  for,  141 
Tumours,  131 
Wounds,  30,  127,  129 
Operations  on  the,  15 
Resection  of  the,  22 
Wounds  of.     (See  Injuries  of,  supra.) 
Ureteral  Grafting,  40 

Stenosis,  18 

Ureterectomy,  27 

Primary  partial,  29 

Primary  total,  28 

— Secondary  total,  28 

Ureteritis,  47 

Ureterotomy  for  Calculus,  16 

for  Stricture,  18 

for  Valvular  Obstruction,  18 

Uterine  Cancer.  (See  Anuria,  Calculous. ) 

Valvular  Obstruction,  Ureterotomy  for, 
18 

Wounds  of  the  Ureter,  30,  127,  129.  (See 
also  Ureter,  Injuries  of.) 


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RD  575  M83  C.1 

On  the  origin  and  progress  of  renal  surq 


2002249138 


